Category Archives: your health care dollar

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stomach flu

On call for my patients, I get a call about flu.

The spouse sounds worried. I speak to the sick person.

“Do you have a fever?”

“Yes, 100.6. I am throwing up and I don’t want to eat.”

“Do you have muscle aches?”

“Not really. I know I need to drink water.”

“Are you coughing?”

“Not really. Not much.”

“Not very congested. Do you have diarrhea?”

“Yes, lots. And my stomach hurts when I eat.”

People often say “flu” meaning “stomach flu” which is not influenza. “Stomach flu” is gastroenteritis, another set of viruses entirely. It could be a bacterial food poisoning, but in 17 years in my rural town, I have seen a total of two food poisoning bacterial infections. Most here are viral.

“Is there blood in the diarrhea?”

“No.”

Viral, then. Blood in the stool is more likely to be bacterial.

The important thing is to stay hydrated. If the person gets too dehydrated, they tend to just keep throwing up and may need iv fluids. To keep them out of the emergency room, I give the following recipe:

One quart of water
one teaspoon sugar
A pinch of salt
(with or without a pinch of baking soda)

If the person is quite nauseated, try drinking just a tablespoon every 15 minutes, with a timer. The electrolytes and sugar help the fluids absorb. Small amounts are easier to absorb and less likely to come up. If they keep throwing that up, go to the emergency room.

“I’m not eating.”

That’s ok. A day without eating won’t hurt you unless you are starting very underweight. Get the fluids in first and then you can go on to chicken soup and try some crackers.

Gatorade or flat ginger ale or pedialyte contain electrolytes too, but the home recipe is fine. And for small children, regular or pedialyte popsicles, because they can’t really drink them quickly.

Most people will recover on their own, especially if they stay hydrated. We don’t tend to try to stop the diarrhea, it’s better just to hydrate people to keep up. If someone is immunosupressed, on chemotherapy or with HIV or after a transplant, they may need hospitalization.

Does the picture look upside down? A bit nauseating or disorienting? I took it in Portland, and yes, it’s upside down.

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Influenza and lung swelling

Influenza is different from a cold virus and different from bacterial pneumonia, because it can cause lung tissue swelling.

Think of the lungs as having a certain amount of air space. Now, think of the walls between the air spaces getting swollen and inflamed: the air space can be cut in half. What is the result?

When the air space is cut down, in half or more, the heart has to work harder. The person may be ok when they are sitting at rest, but when they get up to walk, they cannot take a deeper breath. Their heart rate will rise to make up the difference, to try to get enough oxygen from the decreased lung space to give to the active muscles.

For example, I saw a person last week who had been sick for 5 days. No fever. Her heart rate at rest was 111. Normal is 60 to 100. Her oxygen level was fine at rest. She had also dropped 9 pounds since I had seen her last and she couldn’t afford that. I sent her to the emergency room and she was admitted, with influenza A.

I have seen more people since and taken two off work. Why? Their heart rate, the number of beats in one minute, was under 100 and their oxygen level was fine. But when I had them walk up and down a short hall three times, their heart rates jumped: to 110, 120. I put them off from work, to return in a week. If they rest, the lung swelling will have a chance to go down. If they return to work and activity, it’s like running a marathon all day, heart rate of 120. The lungs won’t heal and they are liable to get a bacterial infection or another viral infection and be hospitalized or die.

I had influenza in the early 2000s. My resting heart rate went from the 60s to 100. When I returned to clinic after a week, I felt like I was dying. I put the pulse ox on my finger. My heart rate standing was 130! I had seen my physician in the hospital that morning and he grabbed a prescription pad and wrote: GO TO BED! He said I was too sick to work and he was right. I went home. It took two months for the swelling to go down and I worried for a while that it never would. I dropped 10 pounds the first week I was sick and it stayed down for six months.

Since the problem in influenza is tissue swelling, albuterol doesn’t work. Albuterol relaxes bronchospasm, lung muscle spasms. Cough medicine doesn’t work either: there is not fluid to cough up. The lungs are like road rash, bruised, swollen, air spaces smaller. Steroids and prednisone don’t work. Antiviral flu medicine helps if you get it within the first 72 hours!

You can check your pulse at home. Count the number of beats in one minute. That is your heart rate. Then get up and walk until you are a little short of breath (or a lot) or your heart is going fast. Then count the rate again. If your heart rate is jumping 20-30 beats faster per minute or if it’s over 100, you need to rest until it is better. Hopefully it will only be a week, and not two months like me!

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Coming soon: The Unaffordable Health Care Act!

Coming soon in the United States!

Aren’t you sick of the Affordable Care Act? aka Obamacare? Time for a new administration and time to get rid of Affordable Care. We don’t want that! Competition, Corporations and Profit First!

Call Mr. Future President Trump, call you congress persons, call your senator, call your representative, call your state ones. Stand up and be heard, US Citizens! Tell them you are all for the Unaffordable Health Care Act! We can kill more small businesses faster! We can make doctors and nurses quit by age 50! We can have more people turn to addictive drugs for numbing and comfort!

Come on, US Citizens! You voted! Now call! The Unaffordable Health Care Act! brought to you by an all conservative all corporate all discriminatory group of unbelievably rich congresspeople and your stinking rich and suing everyone future president.

Or you could say you want Medicare For All! Hey, one system, one set of rules, all US citizens have care, we could start small businesses, business might return to the US since they don’t have to pay more and MORE and MORE for health insurance, wages would go up instead of yearly decreases in health care coverage….nah, US Citizens, you wouldn’t want that, would you?

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Alcohol

Let’s talk about alcohol.

I am a family practice physician and I talk to people of all ages about alcohol. The current recommendation is no more than seven drinks a week for women and fourteen drinks a week for men, no saving it up for the weekend. No more than two drinks in one day for women and no more than three for men.

“What?” you say “No way. Come on, that’s ridiculous.”

My patients don’t say “That’s ridiculous.” After all, they are paying me to do a physical exam and a preventative exam. I am supposed to give them advice. But what is the basis for that?

One drink is defined as a regulation 12 oz beer or 6 ounces of wine or two ounces of hard liquor. If it is a high alcohol beer or wine or liquor, the amount is less.

It is NOT the liver doctors that have given us these numbers. It is the cardiologists, the heart doctors. One drink in women or two in men lowers blood pressure and in general, has good effects. Go over that daily and there is a rebound in blood pressure as the alcohol wears off. Alcohol works in the same way as benzodiazepines: it makes people less anxious and more relaxed and lowers inhibitions. Both alcohol and benzodiazepines are addictive for many people. That is, they develop tolerance, it takes more of the substance to have the same effects, more tolerance and then it takes more and more substance to try to feel half way normal.

Cardiologists qualify this recommendation as follows: there is no recommended daily amount of alcohol that is considered heart protective because there are too many alcoholics. The recommended daily amount of alcohol for an alcoholic is none. The recommended daily amount of alcohol for the general population is none.

Alcohol withdrawal can be very very dangerous medically. I think that the three most difficult things to quit are heroin (and all opiates), methamphetamines and cigarettes, but alcohol is more dangerous. In heroin withdrawal all of the pain receptors fire at once, so it is torture, but people don’t die. With serious alcohol withdrawal, the blood pressure skyrockets and the person can have seizures, a stroke, a heart attack, delerium tremens and can die. In the hospital, benzodiazepines are used to slow the withdrawal, replacing alcohol in a controlled manner.

Alcohol does more than affect the blood pressure. Over time, alcohol can damage the heart and lead to congestive heart failure.

Of course, you know that it can damage the liver and lead to cirrhosis. Cirrhosis is sneaky: as long as there are a few functioning liver cells, the lab work can look pretty normal. The liver makes proteins for the blood and makes proteins that allow our blood to clot. Once there aren’t enough healthy cells to make those proteins, alcoholics will bleed quite spectacularly. If the amount of the protein albumin in their blood is low, fluid leaks from the blood into the tissues: so whatever part is “dependent”, that is, lowest, will be swollen. Alcoholics can have legs with swelling where I can push with my finger and there is a two or three cm dimple. Alcohol also can lead to gastritis and ulcers. If someone can’t clot and they are vomiting blood from an ulcer, the doctor gets a tummyache too, from worrying. Ow. The liver is also supposed to filter all of the blood in the body. As the liver gets blocked with dead liver cells, the blood starts to bypass it. The bypass is through blood vessels in the stomach. Remember that person vomiting blood? The swollen vessels in the stomach are called varicies and we don’t like them to bleed. They are big and can bleed really really fast. The person can die. I don’t like transfusing and really don’t like transfusing 12 units of blood. In end stage alcoholism, the liver no longer lowers the blood level of ammonia. Ammonia crosses the blood brain barrier and poisons the brain. We haven’t even discussed the lack of vitamin B12 and thiamine which can cause unraveling of the myelin sheaths on the long fibers in the spinal cord: this means that the person gets permanent asterixis and “walks like a drunk” even when they are sober. I’m sure I haven’t remembered all of the consequences of alcohol, but that will do for now, right?

How much alcohol daily causes the above charming picture? We Don’t Know. Really. And it is not okay to do randomized double blinded clinical trials to find out. Same with pregnant women: we don’t know if there is a safe amount of alcohol during pregnancy and we bloody well can’t test it. It is safer not to drink while you are pregnant.

In clinic, I ask how much people drink. If they say 1-2 drinks daily, I ask what the drink is. Sometimes they look confused. I explain that I have one patient who has two drinks a day: however, it is a 12 ounce glass with a little ice and a lot of whiskey. I asked him to estimate how much whiskey and he said, “6-8 ounces.” That is, each glass is 6-8 ounces. His blood pressure is not under control and so far I feel like a failure as a doctor with him; he is NOT reducing the amount. In medical school, the two jokes were: How much alcohol is too much? More than your doctor drinks. And: How much does the patient drink? Double or triple what they tell us.

The popular word in college used to be that you could drink one drink an hour and still be “okay”. “Okay” to drive and it would wear off. Sorry, nope. Breathalyzers are now pretty cheap; buy one if you are drinking more than the 1-2 per day. And the college students that are binge drinking 6-8 or more drinks on Friday and Saturday: it DOES have long term effects and it IS doing damage.

Lastly, sleep and depression. If you are having trouble sleeping, don’t drink. No alcohol at all. Alcohol is a depressant. It helps people to fall asleep. But they do not have “normal sleep architecture” and it works AGAINST them staying asleep. People often wake up as the alcohol wears off. And the blood pressure is having that rebound, remember, and often their heart will race. That is withdrawal. If you are having trouble sleeping or you are depressed, do not take a depressant. It makes it worse.

I saw a nineteen year old in clinic who admitted to “occasional” heroin use. “But I’m not addicted,” she said. I said, “Well, that’s good. But I took care of a bunch of people undergoing heroin withdrawal while I was in residency and it looked like one of the most painful things on the planet. So I would advise you to quit while you are ahead.” I saw her a year later and she said, “When I tried to quit, it WAS hard. I was addicted and didn’t know it. I’m off now and I won’t go back.” So if you tell me, no problem, I can quit alcohol any time, I say more power to you. Show me. And if it’s harder than you think, get help.

 

Originally written in 2009 and updated a little today. The picture is just a little fuzzy…like it might be if I was drinking…..

https://www.drugabuse.gov/about-nida/noras-blog/2015/06/addiction-disease-free-will

https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink

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Your health care dollar

I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.

Think about it. What do you want to spend that dollar on?

Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?

How much of your health care dollar do you want to go to corporate competition?

I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?

No, no, no, and no.

Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:

US Preventative Task Force

The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.

You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.

Join Health Care Now and Physicians for a National Health Program.

I want my health care dollar to go to HEALTH CARE.

For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.