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!

Making Your Own Jeopardy Game

Have you every wanted to make your own custom Jeopardy Game for a lecture or class or your daughter's 10th birthday party? Why of course you do! Why doesn't? "But it's too hard!" you say. Well fear not! Here's an online tutorial that I did for the STFM Spring Conference on just this topic. It's really easy (and quite fun) with some FREE online tools!

Make Custom Game Shows for Education from David Koo on Vimeo.

When to start medications for osteopenia?

Consider medications in osteopenia if the 10-year probability of hip fracture ≥ 3% or a 10-year probability of a major osteoporosis- related fracture ≥ 20%. These percentages can be calculated using the online FRAX calculator.   Enjoy!

Refills on Albuterol Inhalers

Each albuterol inhaler has 200 puffs. And since we advised patient to give themselves TWO puffs per treatments. There are about 100 "treatments" in one inhaler. Knowing this, I rarely give out more than 1 inhaler at a time (and I rarely give refills). The reason is that I can use the patient's refill history to give me a rough estimate of the patient's asthma control. If the patient is requesting a refill of their albuterol inhaler every three months, that means they are using their inhaler on the average 1 to 2 times a day (definitely not in control). And if they are requesting their refill only after one month, that means that they are using their inhaler at least three times a day! Yikes!

Imaging for Chronic Sinusitis

Do you have a patient with "chronic sinusitis" and you want to order some imaging?

• Order a limited CT scan of sinuses (without contrast)
• This costs about the same as a sinus x-ray
• But it gives way better images!

Women's Health Screening Recommendations

The Florida Academy of Family Medicine published a Women's Health Screening Recommendations (last edited 4/23/12). It's an interesting read that summarizes the recommendations made by various organizations such as the USPSTF. Here is the official New Release.  (NOTE: Don't click on the image below to see the recommendations—you will only see the first page of the recommendations—click on the link above instead).

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

ASPIRIN Use: A Simple Reminder

Here are the USPSTF guidelines on aspirin use for protection against cardiovascular disease: 

Here are the original recommendation:

The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage.
Grade: A recommendation.

The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.
Grade: A recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.
Grade: I statement.

The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years. 
Grade: D recommendation.