Algorithms for Low Back Pain

Here are the lecture handouts for the FAFP Low Back Pain lecture. Enjoy! Click on the following links to download high quality PDF files for Acute Back Pain and Chronic Back Pain and Radiculopathy Chart.

2019 Hypertension Medication Chart

This chart is based on the 2017 AHA/ACC guidelines. Click here to download the PDF file. Enjoy!

Controlled Medication Agreements

Controlled Medication Agreements for controlled substances are an important part of pain management. For the patient, they offer informed consent on the dangers of longterm opioid therapy and clearly explain the expectations and monitoring requirements of the practice. For the physician, they can offer significant legal protection. This document is offered for educational purposes only and is provided "as is". It is not intended to provide any legal advice or supplement legal counsel. Before initiating any agreement within your practice, I would run your your agreement by a pain medicine specialist and a lawyer. Click here to download a PDF version of this document. Best wishes!

COOL MEDICAL APPS (REVISITED)

It's almost impossible to practice medicine now without using technology. CLICK HERE for a small PDF file with working links! This file is a compendium to a lecture that I gave on Technology and Medicine at the 2015 FAFP Winter Conference. Enjoy! (DISCLOSURE: I have no financial relationship with and of these companies, and I have personally bought every single one of these iOS apps myself—unless, of course, they offer it FREE!)

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.

Physician Heal Thyself

Let's face it, as physicians, we make the worst patients! I don't have high blood pressure! Eh, I'll go on a statin next year. My blood sugar isn't that high! Let me put off my colonoscopy until next year. And I'm not any better! For years I was struggling with fatigue. I blamed it on everything else outside of me—my job is too stressful, I have to wake up too early, I was on call, etc. And for years, my wife kept urging me to get a sleep test. There's no way I have sleep apnea, I reasoned to myself, I'm not overweight, I exercise daily, and I don't snore (at least not that badly). Finally, when I could take the fatigue no longer, I acquiesced and got my sleep test done. After the test was over, I felt stupid! There's no way I have sleep apnea! What a complete waste of time! There goes a hugh deductible thrown out the window. The next day, the result came back: I stopped breathing over 80 times that night!

Wow!

Yet, in a way, I was totally relieved! There was a possible cure for my fatigue. The first night I started using the CPAP machine, my brain started making up for years of lost sleep!—I had a crazy and vivid dream about standing on an cliff beside a frothing ocean teaming with sharks. It was so cool! That's when I realized that this was my first dream in years! YEARS!

Now I'll admit it... Using a CPAP machine is not the world's sexiest thing. But, since I am a Star Wars fan, there is something really cool about looking like a Kotobukiya Star Wars TIE Fighter Pilot! And beside, my kids dig it (and I like to chase them around the house with my mask on).

Of course, I'm just exaggerating—the mask and machine are much smaller than I anticipated! Frankly I was shocked by how far technology has come. And the CPAP machine is no bigger than a "breadbox" (whatever the hula hoop that is). It's a cinch to take on vacations.

So the take-home-message for me is this: Physician heal thyself! Before I can heal others, I need to work on healing myself first. 

So good night and pleasant dreams! Oooooooooo... SHARKS!!!!  

What to say to a patient after a miscarriage?

What do we say to a patient after a miscarriage?

1. You didn't do anything to cause this miscarriage...
2. You didn't do anything to cause this miscarriage...
3. You didn't do anything to cause this miscarriage...

Then...

Listen and weep with the patient.

(Or something like that)

BMJ Study: Why is Rudolph's Nose Red

The BMJ just published an observational study explaining the redness of Rudolph's nose—evidently, reindeer have 25% more capillaries carrying oxygen-rich blood in their nasal architecture than humans. Now, I'm not sure that this investigation answers all the questions—it might answer why reindeers have red noses, but it doesn't answer why Rudolph has a luminescent one! My personal belief?—elf fairy dust.

Depression Medication Chart

Here is a chart that I adapted from UpToDate. It lists the most commonly used antidepressants and their side effects, cost, and other random note. Hope it helps...

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).

Zombies and the CDC

It's about time that the CDC started to take Zombies invasion seriously! Geeeeesh! I mean how many people need to succumb to the vile ranks of the undead before our governmental agencies finally develop policies that protect our frightened innocent!

Algorithm for Work-up of Pediatric Anemia

Here is a simple algorithm for the workup of pediatric anemia. Hope it helps. This handout is from a lecture that I recently presented at the 2012 AAFP Scientific Assembly. (NOTE: Click on the "simple algorithm" link above to download the algorithm. The image below is low resolution).

Diagnosing Diabetes

The ADA guidelines for diagnosing diabetes are not always straight forward—there is a barrage of random numbers to memorize. See if this handout which has an easy pneumonic that I made up for the residents helps to ease some of the pain. Also I have included a handout explaining how to use the Homeostatis Model Assessment (HOMA) to determine whether a diabetic patient has an insulin production problem, a peripheral resistance problem, or both. (NOTE: Don't click on the image below since it will only give you a low quality image; click instead on the "this handout" link above).

Finally, I want to give Dr. George Guthrie profuse thanks for his help in putting together these handouts, and for lending his expertise at the 2012 AAFP Scientific Assembly. Thanks George, you are a blessing. He also added feet and toes and eyes to the pneumonic (to help us remember to do our diabetic feet exams and eye exams). Cool!

COOL MEDICAL APPS

It's almost impossible to practice medicine now without using technology. CLICK HERE for a small PDF file with some cool links for some iPhone and Android Apps that you might find useful. This file is a compendium to a lecture that I gave on Technology and Medicine at Florida Hospital. Enjoy! (DISCLOSURE: I have no financial relationship with and of these companies, and I have personally bought every single one of these iOS apps myself—unless, of course, they offer it FREE!)

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!

Tips on Neonatal Jaundice

(SOURCE: Wikipedia)

Neonatal jaundice! Should I start bili lights or not? AHHHHHHH! Nomograms! Charts! Calculating lab draw times! Assessing risk factors! There has to be an easier way to do this. We are in a technological age aren't we? For goodness sake, we have computers that can calculate the prime derivative of thirty billion electrons playing hop scotch in Andromeda! All I want is for the computer to do some pretty basic math and plot it on a simple nomogram! Ok...

Check this website out: www.bilitool.org. Makes all the calculations MUCH easier... And... You're welcome!

Lice! Lice! Lice!

What do you do when the Nix (1% permethrin) does not get rid of the patient's lice? Well... Assuming that you are doing all the other stuff (using the lice comb, treating family members, etc.), consider using Elimite cream. "But Dave, the patient doesn't have scabies!" you say. Well Elimite cream is 5% permethrin which is 5 times more concentrated than the permethrin in Nix. And, for me, this tip usually does the trick.

Of course there are many other Lice tips and tricks and medications (and some are quite flammable!). This is just what works for me.

Vagisil Cream and Manliness?

Ok... I admit it. Vagisil cream is not the most manly thing a guy can pick up at the neighborhood Walgreens. Heck, I'd rather pick up a box of tampons! But, the stuff does relieve minor topical pain. The main ingredient is benzocaine, a local anesthetic. I've used it on patient's with shingles, minor first degree burns, etc. It's much cheaper than the Lidoderm Patches. And I don't have to fill out a prior auth form only to have the Lidoderm Patch denied because I'm using it off-label!

BUT I do recommend that the wives purchase the Vagisil for their man. Real men do NOT purchase Vagisil... NOT EVER!