REVIEW: PhoneSoap UV Sanitizer and Universal Charger

As a hospitalist, the amount of horrific infections that I see everyday is enough to make a person hide underneath a bed and never want to interact with humankind again. MRSA, H1N1, vancomycin resistant enterococcus, C. diff, and pseudomonas—just to name a few. My job is surrounded with the nasty, oozy, crusty, feculent foulness of human sickness and decay! 

To combat this virulence, I diligently wash my hands, use antiseptic foam, and sanitize my stethoscope obsessively so that I don't spread these microbial minions to other patients or bring those nasty gremlins home to my family. But what about my cell phone? There have been some reports from the Wall Street Journal that our phones are a bacteriological house party. Does that prove cause and effect? Not really. But am I going to wait for a double blind, placebo controlled study? Ummmm... No. 

So a couple of months ago, I bought this interesting UV sanitizer from Amazon call the PhoneSoap UV Sanitizer and Universal Charger: 

Before I bought this UV sanitizer, I was using alcohol wipes. But who knows what damage that was doing to my iPhone over time. Now with this gadget, I can FRY, FRY, FRY! those germs and still have a working PDA!

So does this thing really work? Well... who knows? Without taking cultures from hundreds of phones before and after the "treatment", it would be impossible to definitively know for sure. BUT this much I do know:

1. UV light is HIGHLY DESTRUCTIVE to the DNA of bacteria and viruses and fungi. When I worked in a research lab, we used UV lights in our sterile hood all the time to zap away all the baddies. UV light works!
2. The UV lights in this unit seem powerful! I actually have to remove the plastic case from my iPhone because the UV radiation was actually BURING the case!—just think what it must be doing to the germs! Note that the UV sanitizer appears to be perfectly safe for my iPhone and other plastic gadgets (i.e. no frying or burning smell). Not sure why my iPhone case reacted that way, but it was kind of cool (and weirdly reassuring) to know that the UV light was able to do that.
3. There is a light element on both the top and bottom of the unit so that it completely bathes my phone and other small gadgets in the beautiful glow of non-ionizing radiation.
4. My FitBit One also fits inside the case so I can sanitize my iPhone 5 and Fitbit One at the same time.
5. The unit automatically turns on when closed and shuts off when open. That's good because I would not want to subject my retinas to UV light. Also there is a timer that automatically shut off the light after a few minutes.
6. Unfortunately, the unit is too short to fit my watch (which, I suspect, is another harbor of grossness).
7. You need to supply your own charger. The cord tucks neatly into the side.

So in summary, I love how this UV sanitizer brings me some small peace of mind. My kids use my cellphone all the time, and the last thing that I want is for them to pick up a nasty infection from the hospital. So a message of doom to you microscopic legions of pestilence and woe, be ready to meet your Maker! DIE A HUNDRED DNA-FRYING DEATHS!!!! DIE!!!  DIE!!!!  DIEEEEE!!!!  (Insert bug zapper sound effect here... Also insert funny look from my wife).

NOTE: I'm not getting paid for writing this review, I don't work for the company. and I didn't get a free sanitizer (oh how I wish!). I'm only writing this review because I want to make the world a better place... one cellphone at a time.

RED FLAG FRIDAY: Don't Blow Off Anemia

In a population-based study, 9 percent of adults older than 65 years with iron deficiency anemia had gastrointestinal cancer. Yikes! I know, nine percent doesn't sound like a lot. But think about how many geriatric patients we see each year with anemia! In fact, older adults with anemia had gastrointestinal cancer 31 times as often as adults without anemia. (REFERENCE: Ioannou GN. Am J Med 2002;113:276-80).

Diagnosing Dizziness

Since dizziness can be cause by anything from BPPV to brain tumor, diagnosing the cause of dizziness can be a hugh challenge! This is an algorithm (or map) that I made to help simply the process. Hope it helps! A much higher quality PDF version of this algorithm is available by clicking here.

COOL APPS: Walmart $4 Dollar Medications

Most of us doctors know about the Walmart $4 Medications. Heck, they started it all and now it seems every pharmacy has their own $4 list! That's great for patients! But sometimes, as physicians, it hard to remember what's on that list. So here's the solutions... The Walmart App!

If you have an iOS device, just go to iTunes and download the App! It's a FREE download.

Then, once you run the App, click on the Pharmacy link on the bottom of the page. Then you will have glorious access to the $4 list! And the medications are conveniently listed by categories. It's NICE when technology actually makes our lives easier (unlike some EMR programs).

AND you get to do your Christmas shopping!

(NOTE: Walmart did not pay me to say that... I do most of my shopping on Amazon. NOTE: Amazon did not pay me to say that).

Teaching A Child to Ride A Bike

Ok... I know what you're thinking: what in Sam Hill does "teaching a kid to ride a bike" have to do with medicine? Well, we do have a pediatric obesity epidemic in the good old USA, and I figure that anything we can do to encourage kids to get outside and enjoy some fresh air must be a good thing. That's the official excuse.

Here's the real reason: I've been spending the last two weeks trying to teach my 5-year-old daughter how to ride a bike and I've been saying to myself between bouts of extreme dyspnea, "There must be an easier way!" Imagine a middle aged man profusely sweating while trying to hold up a frightened 5 year old who is wobbling like a drunk dude with meniere's disease on a bicycle!

Anyway, I failed again today! It ended when she fell off and scraped her hand on the pavement. She was frustrated and slightly tearful. So I went inside, wiped the sweat from my face, and looked for help on YouTube...

AND LO AND BEHOLD! THE SOLUTION! GENIUS!
(Especially since I don't have to run like a sweaty pig behind her)!

THE SECRET TIPS:

1. Lower the seat so that her feet can rest comfortably and flat on the ground
2. TAKE OFF THE PEDALS
3. Let her just practice scooting and balancing first!

AWESOME! I'm so excited to try this out tonight!

I always knew the best teacher are able to break down complicated skills into manageable bits. By simply lowering the seat and taking off the pedals, my daughter will be able to learn to balance first without worrying about pedaling, catch her own falls without having me always running beside her, and learn to do starts by herself. Lowering the seat and taking off the pedals! Simply genius!

Testing for Celiac Disease (Celiac Sprue)

Here are some tips regarding Celiac Disease:

• All patients with history of "irritable bowel syndrome" should be tested for celiac disease
• Testing should be done on a HIGH gluten diet
• These test have the highest diagnostic accuracy (better than IgG):
• Endomysial IgA 
• Tissue transglutaminase IgA 
• Diagnosis needs to be confirmed with small bowel biopsy

REVISIT: Glycohemaglobin and Average Plasma Glucose

In a previous post, we discussed a quick tip to calculate the A1C, here is an EVEN QUICKER tip provided by Dr. Eddie Needham (in which Dr. Carlos Dumois started the entire discussion):

Ave Glucose = (A1C — 2) x 30

So a patient with an A1C of 10 would have an average glucose = (10 — 2) x 30. Or 240. Simple awesomeness. 

A Quick Way of Estimating a Normal QT Interval

This is an awesome tip that I learned from Dr. Ernestine Lee (who is also faculty here at Florida Hospital Family Medicine Residency). This tips was given as part of our "Learning Center" morning teaching which our faculty personally do for our residents. Enjoy!

 In a busy practice, calculating the QTc (if your EKG machines doesn't do it for you) can be a chore. A quick way of estimating the normal QT interval is this:

The QT interval should be less than ½ the RR interval

This tips only works if the QRS complex is not widened. I haven't gone through the formal calculations yet to see how accurate this method is compared to directly calculating the QTc. But if sound logical since the QTc is the "corrected" QT interval which takes into consideration the RR interval. If someone does the calculations, please let me know! Cool!

The "Rule of 20" for Pediatric Amoxicillin Dosing

The Rule of 6 for dosing amoxicillin, which we discussed in a previous post, is probably outdated since amoxicillin is typically dosed 80 to 90 mg/kg/day instead of 40 mg/kg/day for children (max 1000 mg per dose). So lets update this rule. For 90 mg/kg/day of amoxicillin, use the following calculation:

   Weight in Pounds  x  20   =   mg dose of amoxicillin per dose

The other change is that this calculation is assuming 2x/day dosing (instead of 3x/day dosing). Let's go through an example. Assuming that you have a 10 pound child in your office, the calculation would look like this: 10 x 20 = 200. So this child would need 200 mg of amoxicillin 2x/day. Since amoxicillin comes in 400 mg per teaspoon, the child would need ½ teaspoon by mouth 2x/day.

The important thing to remember is that this calculation is PER DOSE (and NOT per day). Also, remember that this calculation only works for dosing amoxicillin 2x/day. Double check this calculation with your normal method of calculating the amoxicillin dose. I think you will find that they are pretty close!

Pediatric Bactrim Dosing

Bactrim suspension is dose at approximately 1 teaspoon for every 22 pounds. This is given twice a day. For example, a 45 pound kid would get about 2 tsp by mouth twice a day. Just be aware of the maximum dose. Pretty cool eh? And no calculators involved!

Don't Be Fooled by a Negative C. Diff. Toxin Test

As family doctors, we are typically pretty good at screening for C.Diff. But just because someone has a negative C.Diff. Toxin Test does not mean that they do NOT have C.Diff. Remember that this test is imperfect and frequently needs to be repeated. Often it is better just to start empiric treatment while waiting for the workup.

Just a fever, doc, nut'in else!

For folks who present with only fevers or malaise, check for a urinary tract infection. In the elderly, UTIs commonly present as just malaise. For children, fever is frequently the only symptom.

Warts and Duct Tape

My billing for cryosurgery for warts has gone down considerably since advising my patients to keep their warts covered with either duct tape or band-aids. This tip doesn't always work. But it works sufficiently well enough that I only get out the Cryo Gun about 2 times a week. That's too bad since using the Cryo Gun is kind of fun...

Glycohemaglobin and Average Plasma Glucose

A glycohemaglobin of 6% correlates with an average plasma glucose of about 120. And every 1% increase in glycohemaglobin will cause approximately a 30 point rise in the average plasma glucose. So if we charted it out, it would look something like this:

Just remember 120 at 6%. And 30 rise with every 1%. Remember that these are just rough estimates (and they are probably on the conservative side).

The Walmart $4 Generic List

Here is the link to the Walmart $4 Generic List. Here are some interesting things that I noticed:

1. Albuterol premixed nebulizer solution is on the list (25 vials for $4). That's pretty amazing considering that Proventil HFA costs around $55! Not that I'm advocating that doctors give all their asthma patients nebulizer machines, but the price of a basic nebulizer machine is around $55. This could be an interesting option for our self-pay patients who are really strapped for cash. Too bad there are no inhaled steroids on the list!
2. Terbinafine (Lamisil) is also a $4 med. I can remember a time when it was well over $150. 
3. Metformin ER is generic. Having an extended release metformin may help some of my patients who complain for GI issues from the regular metformin. 
4. Antipyrine/Benzocaine otic drops are on the $4 list. That's good to know for my kids with simple but painful otitis media. 
5. Sprintec and Tri-Sprintec are the only $4 birth control pills on the list. 
6. Fosamax 70 mg is on the list. I had no idea! 

There rest of the list is mostly common knowledge. I'm just waiting for simvastatin to go on the list. 

Tips for Residents: Make your SOAP note NARRATIVE

For new doctors just graduating from residency (or even entering residency), here is my advise regarding documentation. I hope you find it helpful...

As you document your assessment and plan, TALK TO YOURSELF! Here is one time where talking to yourself is not considered insane! Tell yourself what you are thinking in the encounter (“I’m not sure exactly what is causing her fatigue, but either sleep apnea and/or depression is highly likely”). Tell yourself what are some of the things that you want to “rule out” in the future if your current work-up comes back negative (“Consider ordering an EGD if cardiac work-up comes back negative”). Tell yourself what your treatment plan is over the next few appointments (“If patient does not improve with home stretching and NSAIDs, consider starting physical therapy next visit”). Tell yourself the plan for the followup visit (“Consider repeating Chem 7 next visit since we increased her dose of HCTZ”). Tell yourself why you don’t think certain dangerous things are in the differential (“I don’t think that her chest pain is cardiac in nature since there is a strong correlation with spicy foods and laying down at night”). Tell yourself interesting facts about the patient (“She is going with her sister to Maui next week.”)

All these little tidbits are an important part of the “narrative” aspect of good physician documentation. As medicine slowly transitions to EMR, don’t forget this “narrative” aspect of documentation. It is important for medical-legal reasons. It is important for simply being a good doctor!

Is EMR destroying “the narrative”?

Many ERs in my area recently transitioned to electronic medical records. And so far, this has been a terrible step backwards in physician documentation. Instead of getting a concise SOAP note that gives me a reasonable idea of what the ER doctor thought (or even did), I get a vomitus of essentially meaningless word-salad (which is generated, no doubt, from doctors checking off boxes on their computers). Here is a sample which I have transcribed almost verbatim (without the patient's actual name of course):

Have reviewed chart of JOHN DOE and it is ready for final disposition. Condition at discharge—stable. Patient discharged from department. Verbalized understanding of discharge instructions. Verbalized understanding of need for followup and how to access followup care. Verbalized understanding of signs and symptoms to return to ED. Patient discharged from department. Discharge home. Verbalized understanding of discharge instructions [haven’t we heard this already?]. Verbalized understanding of need for followup and how to access followup care. A disposition has been done for JOHN DOE.

What a complete waste of paper! All I want from the ER is something like this: “Johnny has a mild otitis externa. I have prescribed cortisporin otic drops for him. Follow up with Dr. Koo in 2-3 days.” Instead, I literally get five pages of tree-killing faxes that doesn’t even tell me what was prescribed! Nice!

Now I’m sure that some of the kinks of EMR will eventually get worked out. And to be fair, there have been some small improvements recently. However, because EMR relies on doctors typing and clicking on a computer rather than dictating into a voice recorder, I’m afraid that most of the “narrative” aspect of physician documentation will go by the way of the Dodo Bird. And I am saddened that I probably will no longer get something as simple as this from the ER:

“Mr. Johnson has some dizziness. I think this is probably just from some dehydration. I have instructed him to drink more fluids and to decrease his lisinopril from 20 mg to 10 mg a day. He was advised to followup with Dr. Koo in 3 days to recheck his blood pressure. Consider repeating a Chem 7 at that time to reassess his mild renal insufficiency.” 

Now that kind of dictation is HELPFUL, but will likely become increasingly rare in our new era of check-boxes and computer-based templates.

The "Rule of 6" for pediatric amoxicillin dosing

Amoxicillin is typically dosed at 40 mg per kg per day. In the U.S. which will forever be stuck in the dark ages of pounds and ounces (instead of kg and ml), many calculations are required in order to figure out how much amoxicillin to give to a kid. Here is a short cut:

   Weight in Pounds  x  6   =   mg dose of amoxicillin per dose

Let's go through an example. Assuming that you have a 40 pound child in your office, the calculation would look like this: 40 x 6 = 240. So this child would need 240 mg of amoxicillin 3x/day. The important thing to remember is that this calculation is PER DOSE (and NOT per day). And because, amoxicillin is prepared as 250 mg per teaspoon, this kid would need approximately one tsp by mouth 3x/day for 10 days. Piece of cake! And no calculators involved! This rule also works for Pen VK. And it works of Keflex and Augmentin as long as you dose both of them 3x/day. There are other antibiotics that follow the "Rule of 6" but I forgot which ones off hand.

This is a handy tip I learn from my friend and partner Ron Reynolds. And I think he even wrote a paper on it somewhere (I'll check to see if I have permission to publish the original article)...