HOW TO SAVE A LIFE...

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Want to save a life before the end of December?  Do yourself a favor and keep reading...your minding your own business at your company holiday party and someone starts to choke.  What the hell do you do now?  If you freeze, don't worry.  You won't be the only one.  It's a natural human reaction to freeze in an emergency.  This is why certain industries train people to be calm specifically during crisis.  It takes training.  Ok...so now you've unfrozen and Michael is still choking on that giant piece of steak he decided to inhale.  Thanks Michael.  See the picture below on how to perform the Heimlich maneuver properly. 

 

Typically, a person choking won't be able to talk, they will have odd breathing noises or they're starting to turn blue. In the extreme cases this can lead to the person to pass out.  This is all a direct result of the person’s inability to get air into their lungs and deliver oxygen to the the body (specifically the brain).  The universal sign is someone having their hands clutched on their throat.   There are a few steps you should Take when someone is choking.  The American Red Cross has "Five & Five" approach to deliver aid to a choking victim.

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1. 5 quick blows to the back to see if you can dislodge the object. Make sure this is between the person’s shoulder blades

 

2. 5 attempts at the Heimlich maneuver.  Stand behind the person with one hand in a fist and the other grabbing the fist and pull in and up just above the person’s belly button.  If it doesn't work after 5 attempts, try another 5 times before going back to back blows.  If the patient is obese or pregnant, put your hands a little higher.

 

3. You should the alternate between 5 back blows and 5 attempts at the Heimlich maneuver.

 

4. If the patient becomes unconscious, lower them to the floor.  If you can see food or an object in the back of the throat you can try to reach in an grab it.  DO NOT DO A FINGER SWEEP (blindly sticking the finger in the back of the throat if you can't see anything). 

 

5. Start CPR if an object is still stuck and the patient is not responding.   Repeat this sequence of 5 back slaps and 5 chest thrusts until the child responds. Start CPR if the child doesn't stop breathing. 

If the person choking is a child less than 1 year old, place the child face-down on your forearm and slap the back 5 times in the middle of the back using your palm.  If this doesn't work, flip the child over and using 2 fingers press on the center of the child's chest with 5 quick compressions.  

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Please see the links below for a video on how to do the Heimlich maneuver properly and CPR.  Congratulations.  You are now ready to tackle those work parties with confidence that you own that next steak chunk.  No one's dying on your watch....

https://www.youtube.com/watch?v=7CgtIgSyAiU

and

https://www.youtube.com/watch?v=cosVBV96E2g

 

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DO NOT RESUSCITATE & DO NOT INTUBATE (DNR/DNI)

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“We have a 92-year-old male in cardiac arrest. The nursing home reports that he is baseline nonverbal but seemed off the past couple of days. When they checked on him during morning rounds he was found unresponsive. He is currently full code. His initial rhythm was V-Tach. He was shocked once with no return of spontaneous circulation. He received 3 rounds of epinephrine, was intubated and currently has chest compressions in progress. We’ve been working him for 30 minutes and he still has no pulse. We should be at your facility in 8 minutes. Full history available on arrival.” 

 

Unfortunately, the patient would be pronounced dead shortly after arrival. We did everything we could to revive him. The paramedics shocked him to try to get his heart back into a rhythm that is sustainable with life. They performed high quality CPR (chest compressions) and provided medications to try to bring this man back from the dead. We would soon find out that this was a non-verbal patient with multiple medical problems. With the list of medical problems that he had, his chances of surviving such an insult as a cardiac arrest was slim to none to begin with at 92. This brings me to discuss a point that we often ask as doctors, but rarely properly explain. What does Do Not Resuscitate / Do No Intubate (DNR/DNI) really mean?

 

People often tell us, ‘Do everything doctor.’ Unfortunately, in so doing, we often ‘torture’ patients in their last minutes or days of their life. Proper CPR will break the front portion of most of the ribs in someone’s chest. The first time I heard and felt the crack of someone’s ribs from my hands while doing CPR as a medical student, I became queasy.  When we shock someone, we use 200J (Joules) of electricity, which can cause skin burns to the chest. We also inject the patient with medications to try to revive a dying heart.

 

In an overwhelming majority of cases that survive the initial insult, they go on to have tragic permanent neurologic deficits or other major organ insults, which results in unnecessary suffering. A large majority of the unhealthy, chronically ill, older patients will never come off of a ventilator and will require long term care secondary to brain injury sustained during the cardiac arrest. The remainder of their lives will be spent with significant deficits or require 24-hour nursing care.

 

Being on the receiving end of multiple patients in cardiac or respiratory arrest, I feel that we are experts in the subject on what it is like to ‘do everything.’ Unfortunately, the reality is that your chances of survival are not good in an overwhelming majority of the cases (there are always exceptions). There are a lot of misconceptions about this topic and I feel a lot of patients make poorly informed decisions when it comes to what they want done for themselves or their loved ones.

 

When people talk about CODE status (i.e. do you want to have CPR done, intubation and cardioversion) we often present it as ‘if your heart stops.’ A better and more accurate way to ask this question would be, ‘if you die, do you want us to push on your chest, shock you and put a breathing tube into your lungs so we can connect you to a ventilator in an attempt to keep you alive?’

 

The exact rates of who survives are tough to find, but the studies that are available are not encouraging. The statistics are typically broken down in to IN HOSPITAL and OUT OF HOSPITAL cardiac arrest (so those who die in hospital vs those who die out of hospital). To put this in perspective, we will review a few studies. If you die outside of the hospital, one study from Japan found that you have a 2% chance of surviving to hospital discharge with a good neurological outcome. Out of people registered in the CARES registry (a database of 70,000 US patients), about 8% survived to discharge from the hospital after suffering a cardiac arrest. Another Canadian study found that about 11% of patients who had a cardiac arrest survived to discharge from hospital. This number increases in the IN HOSPITAL CARDIAC ARREST GROUP to about 18-20% depending on what study you review. The important part about these statistics are not the numbers though, it’s the type of patient that actually survives and this is where the general public is not being properly informed.

 

There is a large MISCONCEPTION on surviving cardiac arrest and it’s believed to be directly related to television (thank you Hollywood). In the mid-90s Duke University did a study which involved watching 97 episodes of “Chicago Hope”, “ER”, and “Rescue 911”.  Do you know what they found about patients who had CPR during the show? 75% of these actors survived the cardiac arrest with almost 70% being discharged from hospital with no neurological deficits. They were totally fine. This is an extremely different number than the reality of 2-11%.

 

The reality of the situation is that most of the patients who survive are actually younger and healthier patients. The majority of patients that we attempt these heroic measures on are actually unhealthy older patient who likely have almost no chance of survival and very little chance of “good” survival. Patients who have terminal illnesses or are chronically ill fall into this low chance of survival. Any delays to initiation of CPR in these cases (delay of only 5-10 minutes) reveal that there is almost no benefit of these measures. Although these statistics sound dismal, I think it’s important to have this information to make an INFORMED decision. 

 

I think it’s also important to mention that just because someone is DO NOT RESCUSITATE and DO NOT INTUBATE (DNR/DNI) it DOES NOT mean do not treat. We will still provide aggressive medical care up to the point that someone requires resuscitation. We will help supplement breathing, provide fluids, give antibiotics, and other medications to treat your illness. The only thing we would withhold are the heroic measures, which have been proven of limited benefit depending on circumstance.

 

Please feel free to post in the comments section or provide personal anecdotes as you wish. If this is your first time reading one of our posts feel free to follow us on Facebook or our blog (www.reviewmyresults.com) as we attempt to post monthly. We try to do a topic in emergency medicine or medicine in general that is informative or interesting to the general public. Please check out the blog for past topics we have covered. All for now…

 

Dr. Paul

DROWNING

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“We have a 4-year-old male in cardiac arrest after being found at the bottom of a community pool. Unknown time of submersion but the child was seen 5 minutes before by family.  Multiple rounds of medication given, the child has been intubated successfully and we will be at your facility in approximately 5 minutes. Any questions?”  This is a patch that can stop you cold in your tracks, regardless of how seasoned an emergency physician you are.  While this case is a hypothetical one, similar cases have presented to the department during my shifts in the past 10 years.  Drownings are an unfortunate tragedy that is one of the leading cause of death in children under the age of 5.  My wife reminded me that this would have been a fantastic post 3 months ago…here is too keeping everyone awake for the last few weeks of summer.

Did you know that half a million people drown every year worldwide?  Think about that number.  That’s a lot of people! In the United States that number is about 4000 people.  Drowning defined: to die from submersion in an inhalation of a liquid medium.  Other terms that are used but in appropriate by medical professionals are "near-drowning," "secondary drowning," and "wet drowning". 

Drowning is actually a common cause of accidental death in the United States and the leading cause of death in kids less than 5.  The stats show that males, African Americans, kids between 1-5, lower socioeconomic statuses and residents of Southern states tend to be the largest at risk groups.   There are actually 2 peaks of when drowning occurs.  The first is in children less than 5 years of age who are INADEQUATELY supervised in swimming pools, bathtubs or other liquid filled containers.  The second peak is typically in males between the ages of 15-25 in rivers, lakes and beaches  

So, what happens when you start to drown?  The first thing is a period of panic, which is not that shocking.  This will be followed by a loss of normal breathing pattern, breath-holding with a struggle to stay above water.  As soon as water hits the bottom of your lungs, your epiglottis (which is a flap of skin that can cover your wind pipe), will do just that. It reflexively covers your airway.  This will hold you for a few more seconds until you start to fill your lungs with water.  Death occurs from low blood oxygen that affects every organ system. 

So, what the hell do you do if it happens? The most important thing is RESCUE BREATHS.  Rescue and immediate resuscitation are the one things that has been shown to improve the outcome of drowning victims.  Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface.  It’s important to tell you that the Heimlich maneuver or placing the victim in other positions are USELESS and only waste time.   Keep in mind that drowning victims are different than heart attack victims with CPR.  A drowning victim should receive 2 breaths before starting CPR.

I know we have a small following (feel free to like and follow) at the moment but if you can pass this on and share it, that would be great.  If we can bring awareness and save even 1 life it will be worth it.  Until next month...

Dr. Paul

GUN SHOT WOUND TO THE EXTREMITY...

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“We are 7 minutes out with a 26-year-old male with a gunshot wound in the right leg.  No other visible bullet wounds at this time.  He is alert and oriented, complaining of severe right leg pain.  He did hear multiple shots.  Vital signs are currently stable and his bleeding is well controlled with a tourniquet. Any questions?”  This a common EMS patch that we hear in the emergency department in downtown Boston.  This has also become very topical in the press with Chicago’s recent dismal statistics.  Given these, I thought it would be a good time to cover gunshot wounds to the extremity. 

 

Trauma to the extremities (arms and legs) is actually one of the most common injuries that we see in the emergency department.  While not all of them involve gunshot wounds, many of them are assessed in same manner.  We want to make sure that there has been no injury to the blood vessels, bones, nerves and tissue (ligaments/tendons).  Many of these injuries require input from multiple specialists.  They may require a general/trauma surgeon, an orthopedic specialist, a surgeon that specializes in blood vessels, or plastic surgeons.

 

One of the first things pre-hospital is to control bleeding.  The paramedics in our case did a great job of that by applying a tourniquet.  Depending on the location on of the gunshot wound, there may be lots of blood or very little blood.   A tourniquet can often stop aggressive bleeding if applied correctly.   An important part of the evaluation is knowing the anatomy of the limb that is affected.  If you know where the underlying structures are, you can help predict what part of the body is going to be injured. 

 

When the patient is brought in with a gunshot wound to an extremity, the first thing that we do is a trauma survey.  This includes a primary survey, followed by a secondary survey.  We do this the same way for every single trauma patient so nothing is missed.  The primary survey checks airway, breathing and circulation.  If this is intact we will go on to a secondary survey.  In a gunshot wound, this involves stripping the patient completely naked and inspecting EVERY inch of their body from armpits to groin. If the patient is unstable with trauma, they may go directly to an operating room to stabilize life-threatening injuries.  If we determine that it is an isolated injury to an extremity, and it’s stable, we will then perform a detailed exam of the extremity assessing for any damage to the structures we listed above.  This includes (blood vessels, bones, nerves and tissue).   We will then order testing based on these findings.  All gunshot wounds of the extremity will have an x-ray to assess for metal fragments and broken bones. It also allows us to have a rough idea of the course of the bullet as we can see where the bullet is in relation to the entry wound.  Bullets can enter the leg and end up in the belly or chest cavity.  If there are concerns about damage to the blood vessels on the patient’s exam we will then go on to check the blood vessels with special tests called angiography.  The injuries that are present will determine the work up that takes place. 

 

If the patient is stable with an isolated injury but has an injury to the blood vessels in the leg, it depends how severe the injury is.  If they have significant findings they will go to the operating room with a surgeon who specializes in fixing blood vessels (vascular surgeon).  If there are broken bones at the same time, a surgery coordinated between the vascular surgeon and the orthopedic surgeon will take place.

 

Gun Shot Wound X-ray from a patient we took care of in the emergency department

Gun Shot Wound X-ray from a patient we took care of in the emergency department

If the patient is stable with an isolated injury but has no injury to blood vessels we will try to identify other injuries.  If broken bones are present, the extent of these broken bones will be assessed and possibly go to the operating room to fix

 

It's important to note that patients who have these injuries can have a high rate of complications including infections in the bones, developing blood clots, breakdown of soft tissue, tendon/ligament injury and infection.

 

In our case the patient was admitted to the hospital, received antibiotics and tetanus shot.  His gunshot wound was cleaned out with sterile water and loosely stitched.  There was no injury to the vessels or tendons, and was discharged after a day in the hospital.  Until next month!

 

Dr. Paul

 

LYME DISEASE...

Welcome to tick season.  Here in the Northeast, this actually started weeks ago.  So, we are late. Sorry. It was first described in 1977 in Connecticut as "Lyme arthritis".   Lyme disease is caused by a spirochetal infection by B. Burgdorferi, which is carried by the deer tick.  Although Lyme disease has high concentrations in the North East of the united states, it is also found throughout Europe and parts of Asia. The ticks are typically carried by deer and mice.  Lyme disease is actually the most common disease transmitted by ticks. The ticks are found in wooded areas, on shrubs, tall grass and animals.  The tick usually needs to be attached for at least a day to cause an infection.   If you don't realize that the tick has attached, it can take days to weeks to develop symptoms.

The initial symptoms can include a rash that looks like a "bull's eye".  This is known as erythema migrans.   It is red but the center can be normal skin color, appearing like a ring.  It usually occurs within 1-2 weeks of the tick bite.  About 80% of patients will develop this rash. You may also have lack of appetite, headache, fever or myalgia at this time. You may also have no symptoms at all. The rash below is courtesy of the CDC.

Early disseminated disease is the second stage of Lyme infection which is characterized by multiple rash lesions (that typically occur days to weeks after infection) and/or neurologic and/or cardiac findings (that typically occur weeks to months after infection).  Some of these patients have no history of initial infection with Lyme disease.

 

The late stage of Lyme infection includes arthritis of one or multiple large joints (think knee or hip).  This can also have neurological symptoms and problems with memory. This typically develops a few months to a year after initial infection. At this stage problems with memory and chronic skin changes can happen (although this is typical of infections in Europe and not in the US). Another picture below courtesy of the CDC below that nicely summarizes the symptoms in picture form.

 

We test for Lyme disease using a blood test, but it takes about a week to get the test results back. If your medical history and physical exam is consistent with a diagnosis of Lyme disease we will often start treatment before the blood test is back.  It is also possible that some of the blood tests will be negative even though you have clear evidence of Lyme disease (IE the rash described above). 

What should you do if you find a tick or have been bitten?  That often changes depending on a few things.  First if you find a tick on yourself or child, use tweezers to get it off. Pull it off slowly and then wash the area with soap and water.  Some people will keep the tick to show their healthcare provider.  This is not necessary.  If you really want, take a picture with your smart phone.  We would like to know the size, color and if it was attached to your skin.  If the tick was attached less than 72 hours we will typically treat you with one dose of antibiotics if you come to the emergency department.  If it was attached longer then you will likely have a longer course of antibiotics while we await the results of blood tests.  If you find a tick that is just walking on you, you likely do not require any treatment at all.  We are only concerned if the tick was attached, not if it was just walking on you.  If you develop any symptoms or signs of Lyme disease that are listed above, you should see your doctor.  

Some of the things that you can do to prevent getting a tick bite include wearing light colored clothing, long sleeve shirts and pants.  Tuck your pants into your socks (although not fashionable, can save you a tick bite if you're out in the woods).  Showering within a few hours of being outdoors and checking the head, groin, back and armpits are all important.  Make sure to check your children as well.  You can also use bug spray in addition to having your property sprayed if you live in a high tick area.

With many dreams of creepy, crawling bugs in your future…I bid you goodday!

 

Dr. Paul

WHAT TO TAKE IN YOUR KIDS MEDICAL KIT WHEN YOU TRAVEL...

First...sorry for a missed week!  Now this can also be a very broad topic to cover but I'm going to give you some of the basics that I take with me when I travel for the kids, in addition to some recommendations.  This will depend on where you're traveling too (within the United States or internationally), remoteness of the area (5-star resort vs 20-mile hike from civilization) and accessibility of medical care. As with any medications and dosing, make sure you check with your doctor.   If your child has existing medical problems definitely double check with your child's doctor to make sure it’s safe. Got to love disclaimers for the lawyers. NEVER GIVE MORE THAN THE RECOMMENDED AMOUNT.

Again, the other important fact is to know the difference between generic medication names vs brand name.  The best example is Tylenol.  Tylenol is the brand name of acetaminophen (the generic name).   I'll use generic names first as in most cases the only difference between generic vs brand name is marketing

KIDS KIT:  

I’d recommend buying the smaller, travel versions of all of the medications listed below.  It will save you on space. Most of the children's medication is available in tablet/pill form as well which makes it much easier to carry.  It also prevents spilling this in your suitcase!

 

Your Child's Prescribed Medications:  This may sound like a silly addition, but forgetting your kids prescribed medications can be a huge problem and end up costing you a bundle. I recommend carrying any of your child's prescribed medications on your person.  Do not check it in your luggage.  You may also not want to take all of your medication, but make sure you have it in the prescription bottle.  I usually recommend bringing a few days’ worth of additional doses in the event that you get delayed.  You can leave the rest at home.

Acetaminophen (Tylenol):  This is a simple choice.  Not only effective for fevers, it can help with pain control for most things (falls, sunburn, scratches, sore throat).  It's cheap, effective and easy to pack with you.  The typical dosing is 15 mg/kg every 6-8 hours.  How do you figure that out?  This can be tough to dose but if you have a calculator (most of you do on your smart phone) you can figure this out.  I've outlined a step by step formula for proper dosing of this for your child below.  If your outside of the USA, acetaminophen (or Tylenol as commonly known in the US) is called Panadol.  If you exceed the recommended level, it can kill you, so always follow the dosing directions as an adult.  Just some food for thought.

 

DOSING ACETAMINOPHEN (TYLENOL) FOR KIDS STEP BY STEP (always check with your doctor)

  1. STEP ONE: Take your child's weight in pounds (lbs.) and divide that number by 2.2 (this is the conversion of pounds to kilograms).  For example, if your child weighs 22 lbs., they are 10kg (22lbs/2.2 = 10 kg).
  2. STEP TWO: Take the number in kilograms (kg) that you just figured out and multiple that by 15 (the dosing is 15mg per kg).  This will give you the child's proper dose of acetaminophen (Tylenol). In our example that will be 150mg of acetaminophen (Tylenol) (10kg kid x 15mg/kg = 150 mg dose).  
  3. STEP THREE:  Figure out the concentration of acetaminophen (Tylenol). Most come in 160mg/5ml bottle.  This means that in each milliliter of liquid acetaminophen there will be 32 milligrams.
  4. STEP FOUR:  Divide the total dose of acetaminophen that you figured out in STEP TWO above, by the concentration of acetaminophen (Tylenol) that you figured out in STEP THREE.  In our case that means dividing 150mg by 32mg/1ml to give us a final dose of 4.68 ml (rounding down to 4.5 ml is fine...never round up!

Ibuprofen (Advil):  Please note that ibuprofen, Motrin and Advil are all the same drug. Also, an easy choice.  It has a lot of the properties of acetaminophen (Tylenol) as listed above.  This one is cleared by your kidneys while acetaminophen (Tylenol) is cleared by the liver.  It's great alternative coverage between doses of acetaminophen (Tylenol) if you're in a bad way.  We often recommend alternating between acetaminophen (Tylenol) and ibuprofen (ADVIL) every 4 hours.  For example, take acetaminophen at 8am, ibuprofen at 12pm, acetaminophen at 4pm…etc. It’s possible to overdose on Ibuprofen, but really, really hard to do so.   

DOSING FOR IBUPROFEN (ADVIL) STEP BY STEP (always check with your doctor)

  1. STEP ONE: Take your child's weight in pounds (lbs.) and divide that number by 2.2 (this is the conversion of pounds to kilograms).  For example, if your child weighs 22 lbs., they are 10kg (22lbs/2.2 = 10 kg).
  2. STEP TWO: Take the number in kilograms (kg) that you just figured out and multiple that by 10 (the dosing is 10mg per kg).  This will give you the child's proper dose of Ibuprofen (Advil). In our example that will be 100mg of ibuprofen (10kg kid x 10mg/kg = 100 mg dose).  
  3. STEP THREE:  Figure out the concentration of ibuprofen (Advil). Most come in 100mg/5ml bottle.  This means that in each milliliter of liquid ibuprofen there will be 20 milligrams.
  4. STEP FOUR:  Divide the total dose of ibuprofen that you figured out in STEP TWO above, by the concentration of ibuprofen (Advil) that you figured out in STEP THREE.  In our case that means dividing 100mg by 20mg/1ml to give us a final dose of 5 ml.

Diphenhydramine (Benadryl): This is great stuff.  It’s great for allergic reactions of most kinds.  They make it in a 12.5mg tablet that is grape flavored for kids.  The age cut off that we typically recommend is 2 years of age.  If a child is less than 2 you should really check with your doctor.   It can help with the itch after a sunburn or seasonal allergies.  The standard dose for kids is 1-2 mg/kg.  Now, some people will have the opposite reaction to (Benadryl) when they take it and become very awake.  If this is the case for your child, I would proceed with caution.  Dosing of Diphenhydramine 1-2mg/kg

  1. STEP ONE: Take your child's weight in pounds (lbs.) and divide that number by 2.2 (this is the conversion of pounds to kilograms).  For example, if your child weighs 22 lbs., they are 10kg (22lbs/2.2 = 10 kg).
  2. STEP TWO: Take the number in kilograms (kg) that you just figured out and multiple that by 1 or 2 (the dosing is 1-2mg/kg).  This will give you the child's proper dose of diphenhydramine (Benadryl). In our example that will be 10-20 mg of diphenhydramine (Benadryl) 10kg kid x 1-2 mg/kg = 10-20mg of a final dose.  In these cases, I usually will go with the easiest dosing and give my child a 12.5mg tablet as it's between the normal range of the recommended dose.  NEVER give more than the recommended dose. The max dose is usually age based.  <6 years never exceed 37.5 mg/day; 6-11 years never more than 150 mg/day; and ≥12 years never more than 300 mg/day.

Hydro-cortisone cream 1%:  I usually feel that it’s a good idea to have a topical steroid.  It can be used for most minor rashes.  It’s small, easy to carry and relatively inexpensive.   The cut off for using this is also 2 years of age.   It is not recommended to use this on children less than 2 unless you check with your doctor. 

Pedialite Packets:  This is relatively inexpensive packet that you can mix with water.  If you’re traveling in a foreign country where the chances of travelers’ diarrhea are high, this can literally be a life saver.  I’d recommend ordering some online (relatively inexpensive) and if needed, mix it with bottled water.  It's also easy to pack because it's powder form. 


Neosporin:  Or some other form of topical antibiotic cream to use over minor scrapes or cuts.  This can be useful to help prevent infection and to decrease the length of time to heal.  

 

Non-medical additions:  A small pack of Band-Aids and a pair of tweezers for removing splinters are the other two additions I would add to your kit. These can come in handy yet take up minimal space.

 

Other things to consider:  If you’re going somewhere warm, sunscreen is a simple one to forget.  The sun sticks are handy as they can serve as a lite weight alternative to liquid or cream.  Kids tend to like these better.  If you’re going to a foreign country where water or sanitation is a consideration, a discussion with your primary care physician about prescribing a short course or nausea medication like ondansetron (Zofran) or an antibiotic for traveler’s diarrhea is not a bad idea depending on your child's age and existence of any medical problems. 

 

Next week we based on a few requests we will tackle Lyme disease…

 

Dr. Paul  

Neosporin:  Or some other form of topical antibiotic cream to use over minor scrapes or cuts.  This can be useful to help prevent infection and to decrease the length of time to heal.  

 

Non-medical additions:  A small pack of Band-Aids and a pair of tweezers for removing splinters are the other two additions I would add to your kit. These can come in handy yet take up minimal space.

 

Other things to consider:  If you’re going somewhere warm, sunscreen is a simple one to forget.  The sun sticks are handy as they can serve as a lite weight alternative to liquid or cream.  Kids tend to like these better.  If you’re going to a foreign country where water or sanitation is a consideration, a discussion with your primary care physician about prescribing a short course or nausea medication like ondansetron (Zofran) or an antibiotic for traveler’s diarrhea is not a bad idea depending on your child's age and existence of any medical problems. 

 

Next week we based on a few requests we will tackle Lyme disease…

 

Dr. Paul  

WHAT TO TAKE IN YOUR MEDICAL KIT WHEN YOU TRAVEL...

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Now this can be a very broad topic to cover but I'm going to give you some of the basics that I take with me when I travel in addition to some recommendations.  This will depend on where you're traveling too (within the United States or internationally), remoteness of the area (5-star resort vs 20-mile hike from civilization) and accessibility of medical care. As with any medications, make sure you check with your doctor if you have existing medical problems to make sure it’s safe. Got to love disclaimers for the lawyers.

I'll break this post up into 2 sections.  What I bring for ADULTS and what I bring for KIDS.  It's important not to mess this list up, hence 2 separate posts.  The other important fact is to know the difference between generic medication names vs brand name.  The best example is Tylenol.  Tylenol is the brand name of acetaminophen (the generic name).   I'll use generic names first as in most cases the only difference between generic vs brand name is marketing

ADULT KIT: 

I’d recommend buying the smaller, travel versions of all of the medications listed below.  It will save you on space. 

Your Prescribed Medications:  This may sound like a silly addition, but forgetting your medications can be a huge problem and end up costing you a bundle. I recommend carrying any of your prescribed medications on your person.  Do not check it in your luggage.  You may also not want to take all of your medication, but make sure you have it in the prescription bottle.  I usually recommend bringing a few days’ worth of additional doses in the event that you get delayed.

Acetaminophen (Tylenol):  This is a no brainer.  Not only effective for fevers, it can help with pain control for most things (falls, sunburn, scratches, hangovers, sore throat and headaches).  It's cheap, effective and easy to pack with you.  The typical dosing is 650-1000 mg every 6-8 hours. If your outside of the USA, acetaminophen (or Tylenol as commonly known in the US) is called Panadol.  If you exceed the recommended level, it can kill you, so always follow the dosing directions as an adult.  Just some food for thought.

Ibuprofen (Motrin): Also, a no brainer.  It has a lot of the properties of acetaminophen (Tylenol) as listed above.  This one is cleared by your kidneys while acetaminophen (Tylenol) is cleared by the liver.  It's great alternative coverage between doses of acetaminophen (Tylenol) if you're in a bad way.  We often recommend alternating between acetaminophen (Tylenol) and ibuprofen (Motrin) every 4 hours.  For example...take acetaminophen at 8am, ibuprofen at 12pm, acetaminophen at 4pm…etc. It’s possible to overdose on Ibuprofen, but really, really hard to do so. 

Diphenhydramine (Benadryl): This is great stuff.  It’s great for allergic reactions of most kinds and can serve as a sleep aid if you are having difficulty sleeping.  It can help with the itch after a sunburn or seasonal allergies.  The standard dose for adults is 25-50mg.  Now, some people will have the opposite reaction to diphenhydramine (Benadryl) when they take it and become very awake.  If this is the case for you, I wouldn’t take it as a sleep aid. 

Hydrocortisone cream 1%:  I usually feel that it’s a good idea to have a topical steroid.  It can be used for most minor rashes.  It’s small, easy to carry and relatively inexpensive. 

Oral Rehydration Solution:  This is an inexpensive, glucose and electrolyte solution used for rehydration from diarrhea or vomiting.  It’s great stuff as it can be carried in powder form with water added to it.  If you’re traveling in a foreign country where the chances of travelers’ diarrhea are high, this can literally be a life saver.  I’d recommend ordering some online (relatively inexpensive) and if needed, mix it with bottled water.

Neosporin:  Or some other form of topical antibiotic cream to use over minor scrapes or cuts.  This can be useful to help prevent infection and to decrease the length of time to heal.

Nonmedical additions:  A small pack of Band-Aids and a pair of tweezers for removing splinters are the other two additions I would add to your kit. These can come in handy yet take up minimal space.

Other things to consider:  If you’re going somewhere warm, sunscreen is a simple one to forget.  The sun sticks are handy as they can serve as a lite weight alternative to liquid or cream.  If you’re going to a foreign country where water or sanitation is a consideration, a discussion with your primary care physician about prescribing a short course or nausea medication like ondansetron (Zofran) or an antibiotic like ciprofloxacin for traveler’s diarrhea is not a bad idea.

 

Next week we will tackle the kids travel pack…

 

Dr. Paul  

WHY SARIN GAS IS SCARY...

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So, politics aside, let's examine why Sarin Gas and other chemical agents of warfare are horrific things and how they kill.  Sarin Gas was discovered by a German chemist in 1937 as an insecticide.  The Nazi's in all their wisdom (sarcasm) discovered that in addition to serving as an effective pesticide, it was also an efficient way to kill people.  In the United States, exposures to this chemical is rarely seen.  The only place you may come across an exposure to a chemical similar to Sarin gas is in an exposure to strong pesticides which are used in the farming industry. These strong pesticides are known as organophosphates and exposure to them causes organophosphate poisoning.  Sarin gas has been used in attacks outside of the United States with the most recent one in Syria.  It was also used in two separate attacks in Japan. 

Sarin gas works by attacking your nervous system.  It works by messing with the chemicals that allow your nerves to communicate. Specifically, it prevents the breakdown of the chemicals that cause your nerves to fire, resulting in excessive firing of certain nerves.   In the emergency department, we are taught to identify exposure to such chemicals by the acronym SLUDGE (Salivation, Lacrimation, Urination, Defecation, GI distress and Emesis).  This causes excess secretions from every orifice. The deadliest of the side effects are the lungs where you will get excess lung secretions (bronchorrhea) and spasm of the muscles in the lungs (bronchospasm).  These are the two things that will eventually cause you to die from exposure to Sarin Gas. 

The symptoms you feel with exposure to this will be nasal congestion followed rapidly by shortness of breath and then nausea.  Depending on level of exposure, death will typically result within a few minutes from the chemicals effects on the lungs. According to the center for disease control (CDC) It's important to note that the vapors can be released from someone’s clothes for approximately 30 minutes after exposure so decontamination when caring for these patients is extremely important.  Don't ask me who has the pleasure of working with this stuff to do those tests, but that is apparently the length of time it lasts. 

The treatment after exposure is with a medication called Atropine or Pralidoxime, which can help reverse the effects. There are other medications as well but these are reserved for patients with imminent death.  Most people survive mild exposures without complication, any other level of exposure will typically result in death.  

Please post or e-mail us with any topics you may want covered...some suggestions so far include Lyme disease, food poisoning and what to take in your medical kit on vacation.  Any suggestions will be considered.

-Dr. Paul

 

How to deliver a baby behind Dunkin' Donuts...


So, you’re peacefully enjoying a coffee on an afternoon weekend shift (ps that never happens) when suddenly one of the triage nurses runs back with a frantic look on her face stating, “Someone’s about to deliver a baby in the lobby.”  It’s amazing how quickly that single phrase can get everyone into action.  Immediately I asked the secretary to page OBGYN (aka baby delivery experts), asked one nurse to turn on the baby warmer and I found the nearest box of gloves and a facemask (spoiler alert, deliveries are messy).  I then proceeded to run to catch up with everyone else who is heading to the lobby.

 

When we arrived in the lobby this poor lady had a small group of onlookers wondering what all the commotion was in front of the Dunkin' Donuts.  The poor patient was attempting to get out of a wheelchair and onto a stretcher that one of the nurses had rolled out.  I took a quick look behind the privacy of a sheet held by one of the nurses and saw no evidence of a baby yet.   The patient was clearly in distress so the plan was to whisk her into the emergency department.  As we rounded the second corner behind the Dunkin' Donuts the patient just started yelling, “It’s coming, it’s coming!”.  I took another look at this point and sure enough, the baby’s head was out.   “Ok, everybody stop. It’s happening here.”  We then proceeded to deliver the baby right in the hall behind Dunkin’ Donuts.  The steps to do this include controlling the head coming out.  That doesn’t mean pulling it, just placing some mild pressure so it comes out slow, not fast.  If it comes out to fast, you can cause tares.  Most babies who we have to deliver in the emergency department, tend to deliver themselves as often times it is not the first child.  If it’s someone’s first child, you often have more time and they deliver where they are should, in the labor and delivery department.

 

If you are ever in a position to deliver a baby, let me provide you with some pointers.  Ninety percent of the time, there is really not much to do.  Women have been delivering children for 1000s of years before modern medicine, there is no advanced science required.  In MOST cases (there is always a caveat), your only job is going to be to apply very mild pressure to the head as it's coming out and don’t drop the little sucker.  Before the head is completely out, check to see if the umbilical cord is wrapped around the neck.  If it is, using 2 fingers, gently slip it over the head.  NEVER PULL THE HEAD OR UMBILICAL CORD! Don’t worry about which way the head is facing, facing down is the norm and it will likely turn to some degree coming out.  You can have the mother push if the baby’s body is not coming out following the head.

 

You will then deliver one shoulder, followed by another shoulder.   In MOST cases, this will be a very rapid process after the head is delivered (within 30 seconds). The most important part at this point, don’t drop it.  It sounds straight forward, but new babies are liked greased chickens.  Taking your pointer finger and thumb make a very tight grip around the baby’s lower leg, just above the ankle.  Put your other hand in a c-like grip behind the baby’s neck.  Then place the baby on the mother’s chest. 

 

You will then have the placenta to deliver.  Don’t pull on the umbilical cord (please see above).  The placenta should deliver by itself naturally.  You will need to rub on the belly just below the belly button after the placenta comes out to help the uterus to stop bleeding.  Do not cut the umbilical cord until the placenta has been delivered and only if medical personnel are very far away (unlikely situation, but possible).  You can then tie off a spot 3 inches from the baby’s belly button with a piece of string and then another piece about 2 inches farther down.  You can then cut the cord, which is a painless process.  Immediately put the baby back with mom and keep them warm.  Congratulate yourself, you just delivered a baby!

 

In our case, the mother had the baby behind the Dunkin' Donuts and we were able to clamp off the umbilical cord and quickly transfer her back to the emergency department to deliver the placenta and let the labor & delivery team take over.  I was hoping that they would call the baby sprinkles, but they settled on another name.  

 

On a side note, just some quick housekeeping…so a lot of you seem to have liked, shared and provided feedback on our last post (over 6000 people at this point).  We are going to try to make this a weekly event where we write a topic on emergency medicine geared towards the general public. So, if this is something that interests you please like the page and then follow us. We will try to keep it regular, informative and entertaining.  Feel free to leave feedback or post topics you may have questions. Rub the babies back with a towel to stimulate it and help it breath.  

 

All for now...

Dr. Paul

How and why you die from a heroin overdose...

“28 you male, found unresponsive by family. We’ve given 3 doses of Narcan with no effect. The patient still has a pulse but has been intubated without any medications required.  Should be at your facility in approximately 8 minutes.  Any questions?”  This has become an all too familiar patch that comes through from our EMS recently.  There was one point a few months ago where this would happen multiple times on your shifts during a week. According to the Boston Globe, Massachusetts had close to 2000 people killed last year as a result of an opiate overdose.  That’s five times the number of deaths in automobile accidents.  Think about that number.  This doesn’t include the patients that had an overdose and were revived.  

 

While the reason for overdose varies, the mechanics of dying from an opiate overdose typically involve respiratory failure (when blood oxygen levels become dangerously low).  This is caused by the heroin directly binding to receptors in your brain that tell your body to breath.  Once you stop breathing, the oxygen level falls off rapidly. After about 5 to 6 minutes without oxygen, your brain starts to die.  After this point, you will initially develop severe brain damage and eventual death.  Sometimes patients will be revived with the drug naloxone (commonly known as Narcan).  This medication knocks the heroin off the receptors in the brain and allows people to start breathing again.  I will see at least 1-2 patients like this each week in the emergency department. These are people who were dead, but only survived because of this medication.  Sometimes this is enough to change a person’s habits, often they will go right back to using the same drug that nearly killed them within hours.  

 

In some cases, patients will be reversed too late and have severe brain damage or no brain activity at all.  After several days in the hospital and consultation with neurologists to assess for brain function, these patients who are brain dead will be taken off life support and die.  Finally, there are the people who will never be revived and join one of the sad statistics listed above.

 

There is also a tremendous financial impact on society.  The US department of health and human services puts the cost to emergency departments and inpatient care at 20 billion dollars.   That’s almost 55 million dollars a day it’s costing the health system in this country.

 

While there are statics and scientific explanations to explain how you die from a heroin overdose and the financial impact this has on our health system, what we witness is the most tragic aspect, the unmeasurable toll of human suffering.  From the family member who found their loved one blue, unresponsive to the mother or father that I have to sit with and tell them that their 28-year-old is no longer alive.  To the younger sister that went to check on her brother or the father that checked on his daughter and found them blue, unresponsive and dead.  That image will sit with your mother, father, brother, sister, husband, wife, girlfriend etc for the rest of their lives.  What the heroin addict who dies from an overdose doesn’t see, is the emotional shock wave that hits the people that were close to them and those that care for them.   On a somber note…   

 

Dr. Paul 

What happens when you have a heart attack...

So, you’ve developed the crushing, pressure-like pain that causes you to sweat, feel like you want to vomit and you’ve become short of breath. You’ve also noticed you just happen to have had increasing shortness of breath while you’re walking upstairs lately and you have multiple risk factors for a heart attack (diabetes, high blood pressure, high cholesterol, and a strong family history of heart disease) …not to mention you smoke.  Now is probably the time your wife is making you call 911 or you’ve decided to call 911 yourself.  Now these are the classic signs and symptoms of a heart attack.  It’s important to note that not everyone fits the classic signs and symptoms.  The best predictors of a heart attack based on the most recent studies suggest the following symptoms are most likely associated with you having a heart attack…

 

1.     chest pain associated with sweating

2.     chest pain with exertion

3.     chest pain with vomiting

4.     chest pain that goes to both your arms or to your RIGHT arm (not left as everyone thinks).

 

So, what happens when you dial 911?  In our catchment area (the area surrounding our hospital) when someone dials 911 with these symptoms an ambulance will be sent to your location.  Now this maybe just basic EMTs or paramedics.   Some people are not aware that there is a difference between who shows up at your house.  The paramedics have an advanced skill set that allows them to treat many ailments as soon as they meet you by providing lifesaving medicine and helping to identify the cause of your symptoms early.  In the case of a heart attack, the paramedics can diagnose this by doing a heart tracing (EKG) right at your house. 

 

Where I work (and across most major cities within the united states), the paramedics can then send that EKG to the emergency department or call them with the results.  This allows us as emergency room doctors to activate the catheterization team (cardiologists or heart doctors) to be ready for the patient when they arrive.  If the cardiologist or their team are at home (think 2o’clock in the morning), we are able to get their whole team assembled and on the way to the hospital.  In some heart attacks, the cardiologists will be able to take you and open up the blocked vessel that is causing your symptoms.  Did I mention that’s what a heart attack is?  When the blood is cut off from a part of your heart due to a blockage in the arteries that supply blood to the heart, that is a heart attack.  Time is muscle and the heart is unforgiving.  That means that the longer you have the symptoms, the more permanent damage can be done to your heart. 

 

Paramedics are able to start providing lifesaving medication right when they get to you.  They’re also able to provide breathing support and shock you out of life-threatening cardiac rhythms that can result from a heart attack.  When the patient arrives at the hospital, we are ready to take care of them.  If you have questions or comments feel free to post them here or on Facebook!  We always love feedback and/or questions/comments. All for now…Dr. Paul 

Why Flu treatment is useless for most people...

Ok…so there is only so much you can write about blood work to make it interesting and informative, unless it’s your own labs of course.  In that spirit, I’ve decided to change the content of the posts to provide some general, useful (I think) topics in medicine which will tend to focus on emergency medicine. The point of starting this whole little project was to provide access to how doctors think while simultaneously make all of it understandable.  If you, or someone you know still wants their blood work reviewed…we still do that.  For future posts, we’ll start with a topic on Facebook and then carry it over to our health blog for further reading. Comments on the posts, topics you personally want to hear about or just general comments will be welcomed and considered.  This is a work in progress so feedback and requests are always appreciated.  Let us know what you think of the idea! If it doesn’t leave you a little informed, it may just provide you with a conversation piece at your next cocktail party.  On that note, in the spirit of the season (no I’m not talking about lent) let’s talk about why the treatment for the flu is mostly useless…

I’m sure this post will have the Gentec lawyers (part of Roche) after me within the week! Gentec makes Tamiflu the current prescription medication used to treat the flu which is also known as oseltamivir.  All this flu nonsense has been going on since early human existence (please note this is an educated guess), but the use of wide spread treatment of the flu really became popular after the swine flu outbreak in 2009.  Every major health organization recommended treating flu at that time.  So, this became the norm…until the Cochrane collaboration (think of them as the Olympic committee of human research without all the corruption of the Olympic committee) which looks at all the data available from research trials on a drug.

 

You’ll be shocked to learn that the company withheld almost half of the research trials that showed the treatment actually was not as successful as some of the smaller trials showed. The company trial data that they withheld, help the company make billions of dollars as countries certain of widespread outbreaks.  Shocking.  Anyhow, when they finally got their hands on this data the treatment effect of Tamiflu has only a slight benefit.  Most people get sick with flu for about a week.  If you start this medicine within 2 days of when your symptoms begin, you’re only going to get better a half day sooner.  

 

At 100$ for the treatment and side effects like upset stomach, to me it doesn’t make sense (with some caveats below).  This treatment DOES NOT decrease your chance of dying or getting admitted to the hospital!  So here is the down low…MOST people who are healthy, don’t require this treatment. There are some people who do require treatment. The CDC (center for disease control) recommends treatment if you’re really sick and need to stay in the hospital, kids less than age 2, adults over 65, people with certain chronic diseases (asthma, chronic kidney disease, sickle cell disease, diabetes, congestive heart failure and certain neuro conditions like muscular dystrophy), patients on immunosuppressant therapy or with HIV, pregnant females, or nursing home residents.  For the rest of us, Tylenol (acetaminophen), Motrin (ibuprofen or advil) and fluids is going to be the best treatment.  That's all for this week... Dr. Paul