Time’s Up for Sexism in Medicine

I would venture to say that medicine is one of the fields with the most blatant, widespread sexism in the workplace. In watching women in Hollywood stand up to the injustices that women in their industry face, I feel empowered to share the struggles that female physicians face. I wrote about this several months ago but deleted my post in the setting of fellowship interviews as I was concerned that it would seem too controversial or that I would seem as if I were complaining.

I grew up believing that I could be anything and anyone I wanted to be. I excelled in many aspects of life including academics. However, once I entered medicine, I encountered on an almost daily basis people who wanted to strip me of my hard-earned title. Administrative assistants and operators from other institutions on the phone who ask me what my first name is after I introduce myself as “Dr. Villasante.” Not because they want to write my full name but because they want to only write and address me by my first name. Patients who cannot understand that I am a physician even when I introduce myself as such. Who confuse the male nurse as the doctor and me as the nurse.

Our society has such deeply ingrained assumptions that “doctors are male” and “doctors are authoritative” and “women are not authoritative” and “women cannot be doctors.”

Here are some examples.

-We were discharging a patient, Ms. A, on a specialty service. We were talking to Ms. A about setting up follow-up, and she stated “I would like to fellow up with that girl from yesterday. She’s not a doctor though, the therapist that was here.” In fact, she was referring to Dr. J. Our current (male) attending Dr. Y explained that Dr. J was one of his colleague attendings in that specialty and that she had, in fact, trained at this fine institution and was an excellent doctor.

-At a community hospital that we rotate at, I was rounding with Dr. H, a petite blonde female attending. She had laser-sharp precision and was very efficient. We were visiting one of our patients and had a whole conversation with her about her medical care. As we were about the leave the room, she asked, “so when’s the doctor coming to see me?”

-Patient who thought I was his interpreter rather than his doctor, despite the fact that I was the physician who was most involved in his care and made the most management decisions for him.

-It feels that patients and families are much more likely to ask me for directions, some ginger ale, or help to the bathroom than they are of my male colleagues.

-“Can you close the door on your way out, Miss?”

-“Thanks ladies!”

-“As I was telling the girls…”

“Sure, sweetheart.”

“Good morning Doctress”—one of my personal favorites. A well-intentioned but odd greeting a received daily from a maintenance employee at the Veteran’s Hospital my intern year. I just smiled and nodded back.

“Do you have a boyfriend?” – asked by an attending subspecialty surgeon in the middle of the OR during medical school. [A statement like this is not just sexisim but sexual harrassment.]

-“All of my clinic patients are crazy. That’s because I have 70% female patients,” said by a [female] resident physician, overheard a few years ago. “It is hard for me to hear them complain. Just put your big girl pants on already,” she added.

These are just a few examples. These occurrences have become so commonplace for me that I mostly forget them and keep going. I can recall some positive comments as well, like the 96yo woman who told me I was “wonderful” and that she felt so proud that there were so many young women in medicine. Better yet, often gender does not come up at all.

Thinking back to grade school, I remember people being stumped by the following riddle: “A father brings his son into the hospital after they both got into a car accident. The surgeon sees the boy and says, ‘I cannot operate on this boy, as he is my son.’ How is this possible?” The surgeon is the stepfather? The grandfather? The biological father while the other is adoptive? No, the surgeon is the boy’s mother.

Yet, as recently as the summer between college and medical school I was at a party when a young man my age asked with doubt, “but do you really think a woman could be as good of a surgeon as a man?”

Though I encounter wonderful humans who make the daily grind a little bit brighter, from my co-residents to attendings to nurses to patients, I also encounter at least one message every day that says “your status as a female is incompatible with your status as a physician.” I do not blame the individual messengers as, for the most part, they are sending it unintentionally, and not maliciously. They have just been programmed to operate under certain assumptions, and they have not learned to override those assumptions. I am more frustrated with the system that programmed them and continues to program us. And I am hoping to change it.

We can do it

Diet Myths And Fake-Healthy Foods

Does it ever feel like you are bombarded with conflicting messages of “eat this, not that”? With tales of “superfoods” and “clean eating”? Well, I’m about to dispel the rumors.

1. Myth: Kale is healthy, ice cream is unhealthy.
Truth: there is no such thing as a “healthy” food. Let me say that again: THERE IS NO SUCH THING AS A “HEALTHY” FOOD. Spinach is not healthy. Açaí is not healthy. Brownies are not unhealthy. There are eating and lifestyle choices that are “healthier”—that have health benefits such as assisting in weight loss or maintenance, providing micronutrients, or decreasing your risk of heart disease according to studies. But there is no one perfect food that can meet all of your nutritional needs, decrease morbidity and mortality, and make or keep you thin.

Bundt cake

2. Myth: Gluten-free is the way to be.
Truth: unless you have celiac disease, you have no reason to avoid gluten. Gluten is a protein found in wheat and thereby in products that come from wheat, such as anything made with flour. People with celiac disease have an autoimmune reaction to gluten that causes damage to the small intestine and leads to symptoms and signs such as diarrhea, weight loss, and anemia. People with celiac disease who continue to eat gluten can have a variety of complications including increased risk of intestinal cancers. However, there is no evidence that gluten is bad for people without celiac disease. Still, living gluten-free has become the latest trend. “But these cookies are gluten free, so they’re ‘healthy’, right?” Wrong. Gluten free cookies are still cookies. I love cookies, but I see them as a special treat to be eaten in limited quantities. If you read the nutrition label on most gluten-free alternative foods (eg. crackers), they have just as many calories, carbohydrates, and sugars as the wheat-based alternative.

3. Myth: Carbohydrates are evil.
Truth: actually, they are molecules made of carbon, hydrogen, and oxygen that can be broken down for energy. They are neither good nor evil. They are our primary source of energy. American dietary guidelines recommend that carbohydrates make up 45-65% of your diet. Carbohydrates provide 4 calories per gram. Protein also provides 4 calories per gram and fat provides 9. Nowadays there are a ton of diets that promote decreasing your carbohydrate intake (Atkins, South Beach, Zone, Dukan, and ketogenic, to name a few). Some people lose a lot of weight on those diets, but a lot of people also gain all the weight back once they start eating carbohydrates again. The reason why they lose weight is because proteins and fats, the other energy molecules, are more satiating than carbohydrates and often a lot less fun to eat. If you eat less overall, you end up consuming fewer calories than you burned that day, creating a negative net energy balance which leads to weight loss. There is nothing intrinsically “bad” about carbohydrates. They are just yummy, so it is easy to overeat them.

Of note, it is true that there are healthier choices among the carbohydrates. Limiting sugar and increasing fiber intake are the way to go. Reading nutrition labels is key. Added sugar is likely one of the primary contributors to the obesity and diabetes epidemic. There is a such thing as too much sugar, and most of us probably consume too much.

4. Myth: I barely eat but I still gain weight.
Truth: if you are not losing weight, you are not creating a net negative energy balance. It is that simple.

I hear this type of statement from patients and people I know all the time, and I empathize with them, because weight loss is really hard. You may not be eating pie all day, but, if you are not losing weight, what you are eating meets or exceed your calorie needs. You must eat less if your goal is to lose weight. You have to push against your instincts, and it can feel terrible.  Losing weight is not easy, and it is not fun. There are factors that can make weight loss even more challenging, such as energy needs with age, increased hunger with certain medications, and sedentary lifestyle due to medical issues. There is no quick, easy, and painless way to lose weight. Don’t fall for any diet plan that tells you there is. But for those who are overweight (BMI>25) or obese (BMI>30), especially with comorbidities like diabetes, hypertension, and heart disease, it is worth it. For those at a healthy weight (BMI 19-25), weight maintenance is the best preventative medicine.

Apple almond lettuce blue cheese

5. Myth: So I should only worry about calories, then.
Truth: I am not advocating only paying attention to calories. The first reason is that an 1800 calorie diet of cookies and ice cream every day will leave you starved of essential micronutrients and overloaded with sugar. I will talk more about micronutrients (essential vitamins and minerals found in foods that your body needs for its vital functions) in a future post. There are also other aspects to look at, such as limiting saturated fat and sodium intake for cardiovascular health.

Next, you will probably still be hungry so you’ll eat that 700 calorie burger later.

Furthermore, it can be very difficult to calculate your exact energy needs. Our bodies may process some foods differently than others and therefore the calorie estimates on foods may be somewhat inaccurate. It is also difficult to calculate exactly how many calories your body is burning. Most who attempt usually overestimate what they need and underestimate what they take in. For this reason, and also for stress levels, I am not a fan of counting calories. However, if there were an all-knowing observer who could accurately measure the calories you consume versus the calories you burn, your net calories would correlate to the weight you lose or gain (3500 calories = 1 lb).

Steak, eggs, fries

6. Myth: The-latest-diet-craze is going to work for me.

Truth: any diet that accomplishes net negative energy balance will help you lose weight. Adopting a lifestyle that helps you maintain a healthy way is the key, and you have to find what works for you. If low carb floats your boat, more power to you. However, discuss it with your doctor and consider meeting with a nutritionist as low-carb or high-protein diets are not for everyone (eg. Those with end stage renal disease). The same support and advice applies to Weight Watchers or any other diet philosophies out there. There is no one right answer. Find what works for you. The answer for some is in a diet book and for others it is a series of eating rules they have adopted throughout their lives.

Healthy living healthy eating diet myths

7. Myth: If I could just exercise more I would lose weight.
Truth: exercise is awesome and has many health benefits, including supporting weight maintenance, decreasing risk of osteoporosis, and decreasing resting blood pressure for people with hypertension. However, if you just exercise more but do not mind your diet, you will end up eating more to make up for those extra calories burned. Your body has evolved to keep you from starving, so it has sneaky ways of getting you to eat more, sometimes without you even realizing. I say this in a whispered voice, but you can actually lose weight by diet alone; however, it is smarter and healthier to also exercise regularly in order to aid weight loss and to reap the muscle, bone, cardiovascular, and mental health benefits.

With guava

8. Myth: I’m going to gain 10 lbs on Christmas!
Truth: as mentioned above, one lb is equal to a net energy balance of 3500 calories. It is virtually impossible to consume 35,000 calories in one day. It is, however, possible and feasible to eat whatever you want at one meal and still maintain a net even or net negative energy balance over the week. The issue is that many people overeat every day from Thanksgiving until January 1st, and they end up gaining weight. It is often a relatively small gain, such as 2 lbs, but then they do not lose it, and they just keep gaining those 2 lbs every year. Think about what 2 lbs every year does over 30 years. My tip for the holidays is to enjoy and savor your special meals, but to keep all of your other meals just-the-essentials. And if you gain weight in December, lose it in January, and keep it off throughout the year.

Crab clam

The bottom line is, maintaining or achieving a healthy weight and meeting your nutritional needs is all about balance and moderation. There are no healthy foods, only healthier choices.

Medicine Simply Author

My Winter Skincare Routine

Is winter starting to make your skin dry and your lips chapped? Below is my winter skincare regimen as well as tips for keeping your skin glowing all year long.

The first tool I find extremely versatile is Aquaphor. It is an ointment made of 41% petrolatum that serves as a semi-occlusive barrier on the skin. This keeps water and oxygen from being pulled from the skin by the elements, which helps with wound healing and creates a protective moist environment. It does not contain fragrances, preservatives, or dyes so it is good for even the most sensitive skin. It is non-comedogenic so it won’t clog up your pores. I use it on my face, my lips, my hands, and any other dry areas in the evening.

Vaseline is also made of petrolatum but it is 100% petrolatum, so it forms an occlusive barrier and is a lot thicker and stickier.

Some people prefer moisturizing with a cream or lotion rather than an ointment. The difference is that an ointment contains around 80-100% oil and up to 20% water, so an ointment feels oily on your skin and doesn’t “rub in.” A cream, on the other hand, is about 50% oil and 50% water so you will still have an oily layer that doesn’t fully rub in but it is less greasy. Make note, however, that creams often contain emulsifiers and preservatives which can be irritating to the skin. A lotion is similar to a cream but it is an even lighter or less thick formulation and can sometimes contain alcohols for faster drying. Gels and foams are the lightest, so to speak, and they also dry faster the the aid of alcohols. One cream that I find to be non-irritating to my skin and a great moisturizer is Cetaphil Cream. Some providers recommend CeraVe Moisturizing Cream but when I have tried it myself a felt a stinging sensation on my skin, body and face.

Another part of my skincare regimen that I use at night is Differin Adapalene Gel 0.1%. I had mild acne in college and used adapalene (Differin) gel, which at that time required a prescription (now it is over-the-counter!), along with an antibiotic cream called clindamycin. Differin is a topical retinoid that increases skin turnover and wards away acne including blackheads and whiteheads. Retinoids are also anti-aging (you may have heard of prescription Retin-A). I still use a pea-size amount of Differin gel about once every 3-4 nights to maintain clear skin. However, retinoids can be very drying so be sure to moisturize aggressively. Also, wait at least 30 minutes after applying Differin to apply moisturizer as you want to avoid getting retinoid on the sensitive skin around the eyes.

In the morning, I use a tinted CC cream that contains SPF 50. I am currently using IT cosmetics’ Your Skin but Better CC Cream with SPF 50 Plus (Medium) – 1.08 Ounces. I really like the way it gives me a smooth, even skin tone without feeling heavy at all. I use this in the morning with some Aquaphor on my lips. I even use it at night as my foundation and then use a contour stick over it plus mascara, lipstick, and bronzer or blush. I love the fact that it includes SPF for daytime. Protecting my skin from UVA and UVB rays is a priority in order to prevent skin cancer as well as aging and discoloration (and yes, you do need SPF in the winter time too! You can get your Vitamin D from food or a supplement). I will admit, on rotations where I have to wake up at the crack of dawn, I often roll out of bed, brush my teeth, throw on scrubs, and go to work bare-faced, as evidenced in this photo from my intern year.

However, lately I have been making an effort to effort to wear SPF, and to look a little more polished. Also to floss my teeth nightly, but that’s a story for another day.

Lastly, I am a lifelong user of Dove soap. It is the only soap that does not dry out my skin. Because I use Dove I do not have to regularly moisturize my body skin.

And that sums it up. I like to keep my skincare regimen simple and effective. Moisturize at night, preferably with ointment or a non-irritating cream, and wear SPF in the morning.

Hand Washing

How To Avoid Cold and Flu

The winter chill is in the air and everyone around you is sneezing. What can you do to steer clear of cold and flu viruses this season?

Hand Washing
Prevent illness by washing hands frequently!

The best medicine is prevention.

The first step is to avoid getting sick in the first place. Here are my tips:

  • Wash and sanitize your hands frequently. This is the best way to avoid getting sick. In the hospital there are Purell dispensers in front of every patient room and sinks easily accessible. I sanitize my hands before and after every patient encounter. I also wash my hands before eating or before touching my face. I carry hand sanitizer in my purse and in my car.
  • In fact, I avoid putting my hands near my face unless freshly washed. (This is no easy task for a former nail biter!)
  • Avoid people who are sick, especially if you are immunocompromised. If you must come in to close contact with someone who is sick (e.g. your child), wash your hands after any contact with them and before eating or putting your hands near your face. Consider wearing a mask.
    • If you are in close contact with someone with documented influenza, discuss with your PCP whether you should take prophylactic oseltamivir (Tamiflu) medication.
  • GET YOUR INFLUENZA VACCINE! Everyone. Even if you have never had the flu. Even if you are otherwise healthy. I cannot stress this enough to my patients. The influenza vaccine saves lives. Some myth busting:
    • You cannot get influenza from the injected influenza vaccine. You may develop a day or two of malaise and even a low-grade fever as your body creates antibodies to the vaccine. However, you cannot develop influenza.
    • Vaccines do NOT cause autism. More on this in a later post, but read this for more.
    • The vaccine is not 100% effective (nothing is in medicine). However, it significantly reduces the incidence of influenza.
    • See the CDC website for more.
  • Get your pneumococcal (“pneumonia”) vaccine if you meet criteria (eg. if you are above the age of 65 or if you smoke, have diabetes, or a variety of other chronic illnesses). This will help protect you from one of the common causes of bacterial pneumonia. Discuss with your PCP.

But why should I care about avoiding getting a respiratory infection in the first place?

  • According to the CDC, about 36,000 people die of influenza each year.
    • In my ICU rotation my intern year, I took care of an otherwise healthy 45 year old man who developed acute respiratory distress syndrome from the flu and was on a ventilator for 5 weeks.
    • I personally got the H1N1 flu in 2009 and, though I was otherwise perfectly healthy at the time, I was completely out of commission with a high fever for 11 days. This was followed by another week of so of pneumonia and a pleural effusion. The flu is no joke!
  • It’s bad for the economy. No, seriously. According to the CDC, influenza alone causes workers in the US to lose up to 111 million workdays, totaling to an estimated $7 billion per year in sick days and lost productivity.
  • Even a simple “cold” (a viral upper respiratory infection) can be fatal for people with chronic conditions such as asthma and COPD, people who are immunosuppressed (eg. people with cancer on chemotherapy, people with autoimmune disorders on immunosuppressing medications, people with HIV/AIDS).
  • You can pass it on to other people, including people with the above conditions.
  • It’s a hassle! Whether you are the one who is sick or your child, spouse, or loved one is, respiratory infections are a nuisance.

I’ve caught a cold (or flu)! Now what?

  • If you have a fever (temp > 100.5F), consider getting tested for influenza with your PCP or at an urgent care center, as you may qualify for receiving oseltamivir (Tamiflu). You must present within 48hr of symptoms to have any benefit from Tamiflu. This medication can reduce symptoms and shorten duration of illness by 1-2 days.
  • If you have fever and cough productive of sputum (of any color), or symptoms that do not get better within a week, seek medical examination as you could have a lower respiratory infection such as pneumonia.
  • For all other viral upper respiratory infections (symptoms such as sore throat, runny or stuffed nose, runny eyes, sneezing), no medication is needed. You may take supportive medications (i.e., medications to make you feel better). Your body will fight the virus on it’s own.
  • Get rest, drink plenty of fluids, and avoid close contact with other people in order to prevent passing the virus on.
  • If you have malaise, muscle aches, headache, or fever, ibuprofen (the active ingredient in Advil and Motrin) and/or Acetaminophen (the active ingredient in Tylenol) can help relieve those symptoms.
    • Discuss with your doctor whether these medications are safe for you. For example, those with kidney problems and those at increased risk of bleeding should not take ibuprofen without OK from your doctor. Those with liver problems should check with doctor before taking acetaminophen.
    • Seek medical care if you have a severe headache, especially if you do not typically have headaches or if it is the worst headache of your life.
  • If you have a stuffy or runny nose, consider saline nasal spray or using a Neti Pot. Decongestants such as DayQuil can help (contains 3 ingredients: acetaminophen, a cough suppressant, and a nasal decongestant) though I personally never use these myself. Ask your doctor before using decongestants (ingredients such as phenylephrine) especially if you are prone to a racing heart, high blood pressure, or glaucoma.
  • If you primarily have phlegm and a productive cough, you may benefit from a cough suppressant such as Mucinex (tablets) or Robitussin (liquid). I order them frequently in hospitalized patients.

Using these tips I have avoided getting sick so far this season (knocking on wood!). Stay healthy and be well!

See my About page for all disclaimers.

Welcome back!

Welcome to the revamped version of Medicine Simply! I am currently a third year resident physician in internal medicine. I graduated medical school and obtained my MD in 2015. I currently see patients every day, either in the hospital or in the clinic, under the guidance and supervision of attending physicians. This summer I will complete my residency, apply for a full, independent medical license (I currently operate on a training license), and sit for the boards in order to become “board certified” in Internal Medicine. I will also begin specialty fellowship in July 2018.

In the next series of posts I will be providing you with affiliate links through Amazon Associates. For example, in my last post, I provided a link to Afrin No Drip Extra Moisturizing Pump Mist 15 ml, a brand name version of the nasal decongestant oxymetazoline, as I have used oxymetazoline in practice. If purchases on Amazon are made by readers who click on the links, I will make a small commission. I am not partial to any particular brands and will aim to present multiple options when available. I will only highlight products and over-the-counter medications that are evidence-based and/or widely recommended in practice. I have already turned down offers to review herbal supplements because I do not believe in those products, for example.

Future posts will include further medical lifehacks such as how to avoid cold and flu, recommendations on my personal favorite skincare products, and information on your burning questions such as, what does “gluten-free” really mean? I will always continue to incorporate my experiences as a resident physicians. Stay tuned!

How to Stop Nosebleeds

*Buzzzz* My pager buzzes with the following message: “patient in 233 having a severe nosebleed, come now.” The patient is a 72yo woman on aspirin (an antiplatelet drug) and warfarin (an anticoagulant). When I walk into the room, multiple staff members are surrounding the patient. One is holding gauze under her nostrils as bright red blood is dripping down. I see that the patient is breathing normally and thinking clearly and is not in distress.

I instructed the nurses to hold firm pressure at the tip of her nose for 5 minutes without letting go. Also to keep the patient’s chin close to her chest in order to prevent blood from going into her trachea. Instead any blood would drip back into her esophagus or out her mouth. However, sensing the nurse’s reluctance, I placed my gloved hand over the patient’s nose and pinched firmly for 5 entire minutes without stopping. It must be a firm hold, to the point of slight discomfort to the patient. During the hold, the patient had some clots come out of her mouth during the first minute or so, but the bleed seemed to be slowing down. I timed the 5 minutes on the wall clock and then examined the patient’s nose.

When I let go, there was no further obvious bleeding. On exam with a light, there was an oozing spot visible in her right nostril. I ordered oxymetazoline (Afrin) nasal spray and had her RN apply two sprays to each nostril in order to cause constriction of the blood vessels in the patient’s nose. The patient had no further bleeding.

Most (about 90%) of the time, epistaxis (aka a nosebleed) comes from the front or anterior part of the nose; specifically, from a group of blood vessels called Kiesselbach’s plexus, as shown in the photo below. Compressing them can stop this kind of bleed.

©2017 UpToDate, Inc. and/or its affiliates.

If a nosebleed happens to you or a loved one at home,

  • 1. the first step is to make sure that the person bleeding has a pulse, is breathing, speaking, thinking clearly and able to protect their airway; if any doubt on their ability to protect their airway, call 911.
  • 2. The next step for those who are safely protecting their airway is to begin by applying firm pressure as such, with the chin tucked close to the chest:
Anterior nasal pressure and chin tuck. Copyright Medicine Simply.
Anterior pressure, side view. Copyright Medicine Simply.
  • 3. Do not let go for a minimum of 5 minutes.

During the process of holding you may see some clots come out of your mouth or feel them go down your throat. However, if you continue to have unchanged, profuse bleeding, in particular down the back of the throat, despite firm anterior pressure, call 911 and go to your closest hospital emergency department as you may have a posterior nasal bleed. Posterior bleed tend to be dramatic–they don’t drip, they run like an open faucet. For anterior bleeds, however, firm pressure should noticeably dampen the bleed.

  • 4. After 5 full minutes of firm pressure, let go and inspect the nose for bleeding. If any further bleeding, apply two sprays of Afrin to each nostril and continue to hold firm pressure for another 5 to 10 minutes. If after 15 total minutes the bleeding has not stopped, seek emergency medical care, as you may need nasal cautery or packing by an ENT or emergency room physician or advanced provider.
  • 5. If bleeding has stopped but there is some oozing at the source, it is reasonable to apply two sprays of Afrin in the nare. Watch carefully for at least 30 minutes to ensure no recurrence of bleeding. Make note that Afrin is a great vasoconstrictor and decongestant but it should only be used for more than three days in a row as it can cause rebound nasal congestion.
  • 6. Once the bleeding stops, care for the site of bleeding by gently applying an antibiotic ointment such as bacitracin three times daily for three days.

If nosebleeds happen to you frequently, discuss them with your primary care provider (PCP) in order to discover why they may be happening.

See About Me page for Disclaimers.

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Brain Death and Basketball

In reference to the recent unfortunate events regarding basketball player Lamar Odom, I have heard many inconsistent reports, from declarations that he is “brain dead” to reports that he woke up and spoke. This got me to thinking about how brain death, death, cardiac arrest, and altered levels of consciousness are often inaccurately portrayed in the media, and I wanted to clarify a few misconceptions 

First of all, when someone is brain dead, they are, for all intents and purposes, dead. Death is defined as brain death and/or cardiopulmonary death. If Odom were brain dead, he could not wake up. If he really woke up, he was never brain dead. Brain death = legal and biological death. Brain death means that the person has no function in their cortex (upper brain, which produces consciousness) OR in their brainstem (the “rudimentary” brain, so to speak, which controls functions such as breathing). When someone is brain dead, their entire brain is permanently functionally damaged and can never return to a functioning state in any way.

brain2

The way that we as doctors assess for brain function is first by clinical exam. First, we make sure to minimize factors confounding the exam (for example, turning off medications, or warming someone who had been hypothermic).

If someone is awake, alert, and conscious, they are demonstrating that they have at least some cortical (upper brain) function. When someone has altered levels of consciousness (for example, they are somnolent) The exam then aims to answer “how good is their cortical function?” — can they speak? Can they interact or express themselves in some way? Can they visually track? Can they follow simple commands?

People who are unconscious can sometimes have spontaneous movements (such as abnormal posturing), but they will not have purposeful movements or meaningful interaction with their surroundings.
When someone is unconscious, we want to see if they have some “lower brain,” or brainstem function. We start by examining cranial nerve reflexes. Cranial nerves are peripheral nerves that have their roots in the brainstem, and they control head and neck functions such as facial expressions, facial sensation, and pupil dilation and constriction. Reflexes mediated by cranial nerves include pupil constriction upon stimulation with light, blinking upon touching the cornea, and gagging when the back of the throat is stimulated (such as with a q-tip). Someone without brainstem function (i.e. a brain dead person, or equivalently a dead person) has fixed dilated pupils, will not react to stimulation of their corneas or throat, and cannot breath on their own, as the brainstem controls the respiratory drive.
What does it mean to “pull the plug” or remove “life support” from a brain dead person? Often, brain death is declared on a person who is intubated and on a ventilator—they have a tube (an endotracheal tube, named because of its position within the trachea) down their throats, and this tube is connected to a machine called a ventilator that moves air in and out of the lungs using positive pressure. The drive to breathe is located in the brainstem, so a brain dead person will not breathe on their own if the breathing tube is removed (if they are extubated). Once they experience respiratory arrest, their heart will soon stop beating and pumping because it is not being supplied with oxygen (the heart’s drive to beat is actually independent of the brain, but without oxygen the cardiac muscle will stop functioning). So, someone who has experience brain death will, inevitably, if left untouched by medical devices, swiftly experience cardiopulmonary death.

ventilator

Keeping a brain dead person on a ventilator is not “keeping someone alive”—it is oxygenating and perfusing a corpse. The medically appropriate next step after someone is declared brain dead is to extubate them within a reasonable amount of time (eg. sometimes a few hours to a day, to give the family time to process). There are situations, however, where a person is  NOT brain dead, but they are breathing with the help of a ventilator. Sometimes, based on the patient’s prior wishes, his or her durable power of attorney (often a spouse, a parent, an adult child) makes the decision to extubate them and let nature take its course.

Why does the heart keep pumping if the brain is dead? That is because the heart beats independently of the brain. The heart has its own pacemaker, and the heart will continue to function (if it is a viable organ) for as long as it continues to receive oxygen. A viable heart removed from the body would continue to pump if it received adequate tissue oxygenation. When a person dies naturally (i.e., when they are not intubated and on a ventilator), however, both brain death and cardiopulmonary death occur (the heart stops once breathing stops, and breathing stops once the brain dies. Sometimes, the heart dies first, and then the brain dies because it is not getting oxygenated blood flow).

Cardiac arrest occurs when your heart suddenly stops. Cardiac arrest is not the same as a “heart attack,” or myocardial infarction, which is when a coronary artery (vessel that brings oxygenated blood to the heart) gets blocked, such as by a clot that gets stuck in a plaque (plaques often form on vessels, narrowing of the vessel). A heart attack COULD lead to cardiac arrest, but there are several other events that can also cause a cardiac arrest. Also, the majority of heart attacks do not cause cardiac arrest.

Coronary artery anatomy
Coronary artery anatomy

Sometimes, however, a person can have serious brain damage and can be in a coma for days, but can still have brain function and a chance for some sort of meaningful recovery. I recently saw two patients around the same time who had experienced cardiac arrests. One died, and one is alive and interactive. Both received CPR at the scene, and both were brought to the hospital and their bodies were cooled (therapeutic hypothermia). Both were intubated and on ventilators, and unresponsive for several days. Bill had his eyes open, was at first not visually tracking, but was withdrawing to pain, and was moving his arms on the bed spontaneously. Tim was completely unawake, with eyes closed, not moving, not responding to pain; however, he did have cranial nerve reflexes. We did a test called somatosensory evoked potentials (SSEPs), which showed that Bill had some cortical activity, while Tim had only brainstem function. Neither was brain dead, but Tim had a very poor prognosis based on clinical exam and SSEP; Bill’s prognosis was at that point unclear. After a few days, however, Bill started tracking our faces with his eyes. He started following simple commands (at first, he would blink and shut his eyes on command. Next, he would squeeze hands on command. Then he became able to give a thumbs up, lift his legs). Soon Bill passed spontaneous breathing trials and he was extubated. He was very disoriented, not knowing where he was or what year it was, but he could verbalize, and he could tell me his name, his wife’s name, his hometown. Day after day, he continued to get better. He still has serious neurologic deficits, but he is awake and alive. Tim, on the other hand, did not get better. Each day, he looked the same as the day before. His family decided to extubate him, and he eventually passed.

Cardiac arrest is a serious event, and most who experience it die. However, like my patient Bill, there are some who do survive. However, most who survive a cardiac arrest are left with serious permanent neurologic deficits. Only a very small fraction, however, return to their baseline functioning. Someone might return to baseline–for example, if he or she were were young and healthy at baseline and received effective CPR right away.

How Your “Natural” Supplements Could Kill You.

Today during our “morbidity and mortality” lecture, we discussed a case of a woman who suffered a devastating stroke because she was taking naturopathic dietary supplements. She had a list of 70 different homeopathic supplements that she was taking, one of which contained thyroid hormone from animal organs. She presented to the hospital with a heart arrhythmia called atrial fibrillation as a result of the off the charts thyroid hormone levels in her body. Soon after arriving to the hospital she suffered a major stroke which left her permanently disabled (new-onset atrial fibrillation can put patients at risk of forming clots in the heart which can travel to the brain and cause ischemia, or inadequate blood supply, leading to cerebral infarction–commonly known as stroke).

Earlier this month I took care of a patient who died of metastatic breast cancer because she refused conventional treatment. She was diagnosed with breast cancer in her 40s, 7 years prior to her death. At that time, she had a very good chance of being cured with surgery and local radiation alone. However, she was a firm believer in naturopathic medicine, which essentially teaches that the body can heal itself, and she refused conventional or allopathic treatment. She was an educated person, and she had received a doctorate in a branch of alternative medicine. Eventually, her cancer became metastatic, infiltrating her liver, her bones, a diffusely throughout her tissues (known as “carcinomatosis”). She did agree to some chemotherapy towards the end of her life, but by that point it was too late. When I met her, she was bed bound, in severe pain all over her body, with chest tubes in place draining up to 2 liters per day of pleural fluid (fluid from around her lungs). The morning I met her I assisted her husband in draining her chest tubes, a task he meticulously completed every day. They were a very loving couple, speaking gently and kindly to each other in the most frustrating of circumstances, and she was a very sweet lady. After she died, after I left her room, I went somewhere private to cry. I had bonded with her. After some time passed, I also felt ashamed that she had died a preventable death. Somehow, we as allopathic doctors had failed her by not doing a good enough job of convincing her to allow us to treat her with evidence-based medicine. Maybe we hadn’t pushed hard enough, because we thought it was a losing battle.

Last week I met a patient with gastroesophageal reflux disease (GERD) who did not believe in taking medications and refused to take her Nexium (omeprazole, a proton pump inhibitor which decreases the acid content of the stomach). She experienced an uncomfortable feeling in the back of her throat after eating, and she was convinced that she had food allergies. A naturopathic doctor had diagnosed her with a whole slew of food allergies. In clinic, skin testing to the common food allergies, including the ones diagnosed by the naturopath, were all negative. The one treatment that would make her feel better was the proton pump inhibitor; however, due to misinformation and her mistrust of conventional or allopathic medicine, she would continue to feel lousy.

In medical school I took care of a patient who went into liver failure because she was taking Herbalife. Here, a local police officer lost his job because he was taking a weight loss supplement that contained amphetamines.

There are countless stories like this. In the US, about half of the adult population uses dietary supplements. The US Food and Drug Administration (FDA) defines dietary supplements as “vitamins, minerals, herbs or other botanicals… amino acids, enzymes, organ tissues, glandulars, and metabolites… extracts or concentrates” and may be found in many forms such as “tablets, capsules, softgels, gelcaps, liquids, or powders.” Dietary supplements are a $34 billion per year industry. These supplements are marketed as “natural” and they are sold at “health food stores,” GNC, Whole Foods, etc.

The reality is that dietary supplements are not categorized by the FDA in the same way that drugs made by pharmaceutical companies are, and thus they are not held to the same rigid standards and regulations. Dietary supplements do not even need approval from the FDA before they are marketed to consumers. Under current law, the responsibility of monitoring safety and effectiveness falls not on the government, but on the manufacturer. In other words, I can bottle a concoction of sugar and rosehips and write on the label that my product cures cancer, diabetes, and heart disease, and the government will not stop me.

Though regulations were created in 2007 to “ensure the identity, purity, quality, strength and composition” of supplement products (in other words, to make it more likely that the bottle labeled as Vitamin C actually contains Vitamin C), the government does NOT enforce these regulations. Straight from FDA.gov: “Unlike drug products that must be proven safe and effective for their intended use before marketing, there are no provisions in the law for FDA to ‘approve’ dietary supplements for safety or effectiveness before they reach the consumer.” Under the DSHEA law signed in 1994 by President Clinton, dietary supplements are regulated retroactively; manufacturers are supposed to report adverse effects of their products to the FDA. In other words, the onus of regulating supplements falls on the manufacturers of these products, who have a vested interest in selling them and making money.

Furthermore, the dosing is completely unregulated. As mentioned on FDA.gov’s Q&A section, “Other than the manufacturer’s responsibility to ensure safety, there are no rules that limit a serving size or the amount of a nutrient in any form of dietary supplements. This decision is made by the manufacturer and does not require FDA review or approval.” A supplement may contain very high levels of a compound, or they can contain such a minimal amount that a person would have to take thousands of pills to have any kind of effect.

Many supplements are manufactured abroad, and often contain dangerous contaminants, including lead.

There is one reason alone to take vitamins or supplements: when your allopathic healthcare provider (board-certified MD or DO, or ARNP/PA working under the supervision of one) prescribes it. Notable examples include

  • When you have certain types of anemia that require supplementation with Vitamin B12, Folic acid, and/or iron.
  • When you have been diagnosed with Vitamin D insufficiency or deficiency
  • When you are trying to become pregnant, and prenatal vitamins are prescribed.
  • Or when studies have otherwise shown that taking that supplement is 1) safe and 2) effective in treating your problem.

Why is there a demand for dietary supplements? Now, this is just my personal conjecture… But perhaps we buy supplements because, in spite of the best evidence-based conventional medicine, people still get sick and die every day. The big bad pharmaceutical companies have big bad reputations, and conventional doctors make mistakes every day that hurt and kill people (“iatrogenic” events). We place unreasonably high expectations on medicine, and by proxy on doctors, to be perfect and Godly, Almighty Fathers and Mothers who keep us safe and take away our ailments. And conventional medicine very often fails to accomplish either. So, in rebellion, or perhaps with our last ounce of hope, we buy magical potions sold with impossible promises. Because we need to believe that something will fix us. Because illness is scary. Because death is scary.

My suggestions to the reader are:

  1. Know what you are ingesting.
  2. Do not waste money on products that are at best ineffective, and at worst dangerous.
  3. Put your faith in scientific evidence, not in false promises.

[PS This post is in no way implying that all alternative and complementary practices are harmful. The stipulation is that they be evidence-based–meditation and other stress-relieving techniques, for example, have some proven benefits. Otherwise, that they be low-risk and have subjective benefits–for example, massage therapy makes me feel great. In any case, alternative and complementary practices are not adequate substitutes for conventional medical therapy. The purpose of this post is to make the point that certain active compounds found in dietary supplements can be very harmful.]

What is ALS?

Over the last few weeks, many of us have seen video after video of friends and celebrities taking on the “Ice Bucket Challenge” to benefit ALS research. So, what is ALS? And why does it need to be researched?

In a sentence: Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a progressive neurodegenerative disease for which there is currently no cure.

What it looks like clinically, and what’s causing it to look that way:

–ALS is “neurodegenerative” because “motor neurons,” or nerve cells that control movement, are damaged. Motor neurons are damaged because they accumulate a build-up of “inclusions,” or clumps of dysfunctional proteins, which cause the cell harm. These damaged neurons then cannot signal muscles to contract and release as they normally would. As a result, patients with ALS develop muscle weakness and, eventually, paralysis.

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–Loss of motor neurons eventually impairs the function of limbs, head and neck muscles, spinal muscles, and respiratory muscles. That means that, eventually, people with ALS will not be able to walk, speak, eat, or breathe.

–In ALS, the motor neurons in both the brain (“upper motor neurons”) and the brainstem and spinal cord (“lower motor neurons”) are affected. Signs of upper motor neuron involvement include increased reflexes, “spasticity” (increased muscle tone leading to muscle tightening), and lack of coordination. Signs of lower motor neuron include muscle atrophy and “fasciculations,” or muscle twitches.

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–There are different variations of ALS where the initial symptoms and areas affected differ, and where additional symptoms such as dementia are present.

Who gets it? ALS most often affects people between ages 40 and 70, but can affect individuals in their 20s and 30s. Sometimes it runs in families, but most often people with ALS have no known affected family member. There are about 2 cases per 100,000 in the US population newly diagnosed each year (about 5,600 new cases per year). About 30,000 people in the US are currently living with ALS.

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Left: baseball player Lou Gehrig (right) after whom the disease was named. Right: Professor Stephen Hawking, living with a form of ALS.

Is it life-threatening? Yes. Respiratory failure is the most common cause of death in ALS. The median survival from the time of diagnosis is three to five years.

What are the currently available treatment options? Though there is no cure, some treatment options modestly modify the disease. A drug called Riluzole which targets the pathway of the neurotransmitter glutamate is the only drug shown to impact survival, and even so only increases lifespan by months. Otherwise, patients must be given supportive care to assist them with functions of daily living.

What could we use in the future? There are several therapies being tested in animals and humans, and there are therapies that have been proposed for future trials including drugs, stem cell treatments, and gene therapy.

The aim of the ice bucket challenge is to raise money for ALS research by encouraging donations to the ALS organization.

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Benign Skin Growths and Spots

During my dermatology elective, I encountered countless patients who were concerned about growths on their skin that were, in fact, harmless and very common. There are thousands of lesions that can appear on the skin, but here I will discuss a few of of the most commonly seen benign skin spots and growths. I will also discuss what kind of changes to be cautious of when examining growths and moles. When in doubt, consult with your dermatologist.

Brown Spots

1.freckles-boy-flickr-NoSpareTime Freckles (“Ephelides”): these small, flat light-brown spots are small, multiple, and irregularly shaped. They appear in childhood, darken during the summer months, and lighten during the winter months (waxing and waning in response to sun exposure). They are due to a local, superficial accumulation of melanin, the protein the gives pigment to our skin and protects us from the sun. They are more common in lighter-skinned individuals who sunburn more easily. Sometimes these fade with age. The best way to avoid new freckles is by good sunprotection.

2. “Solar lentigos” (aka liver spots, age spots, or sun spots): these brown spots appear similar to freckles, but have sharper margins and sometimes stand alone. They can be found on the backs of hands, the shoulders, and the head and neck of adults. They are caused by sun damage acquired over time, but their appearance is persistent (they do not darken or lighten with the sun, or with time). They are due not only to a local accumulation of melanin, but also to a local increase in the cells that produce melanin (“melanocytes”). Some consider them to be flat versions of seborrheic keratoses (see below). Though not harmful, they can be treated for cosmetic reasons with freezing (“cryosurgery”), chemical peels, or certain lasers.

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3. Café-au-lait spots: these light-brown “macules” (flat, smaller than 0.5cm) and “patches” (flat, greater than 0.5cm) appear within the first year of life. They are due to a local increase in melanin. If a child has greater than 5 café-au-lait spots >1.5cm, they should be tested for syndromes such as neurofibromatosis.

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3. Junctional nevi: these darker brown, sharply bordered, flat lesions are a type of mole (“nevi” = mole). Moles have specific features under the microscope. They do not need to be removed unless there are features concerning for melanoma (see the ABCDE rules below). Removal is by cutting them out (“excision”); be mindful that excisions leave scars.

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*There are many types of flat and elevated moles. Some have more pigment, and some are skin-colored. We will discuss at the end how to monitor moles.

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Signs of Wisdom – seen more commonly in people age 30+

1. Seborrheic Keratoses (SKs): sometimes referred to as barnacles, these light tan to dark brown waxy growths appear to be “stuck on” to the skin, as if they could be peeled off with your fingernail. They have a rough, warty surface, and they can grow up to 1” (2.5cm) in width. SKs are caused by skin cells from the top layer of the epidermis (“keratinocytes” in the “stratum corneum”) sticking together. Some think they may be related to sun exposure. There is no need to remove these growths, as they are completely harmless, but if they become irritated or cosmetically undesirable, they can be removed by freezing (“cryotherapy”), burning with an electric current (“electrocautery”), or scraping.

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2. Skin Tags: these smooth, fleshy growths hang on to the skin by a little stalk. These are commonly acquired in areas of friction. Though they are harmless, if irritated or undesired they can be removed by snipping with scissors or freezing.

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3. Cherry angiomas: the cherry-red raised round bumps (“papules”). They often start out flat and become dome-shaped. They are caused by an abnormal growth within capillaries, the smallest blood vessels. In the rare case that the patient desires removal, they can be burned off with electrocautery or zapped with a laser.

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Monitoring moles and other growths and spots:

One of the most important rules of thumb in screening for melanoma is the ugly duckling sign: spotting the mole or growth that does not look like the others. A lesion is often not concerning if you have others that look like it on your body.

Monitor your moles by following the ABCDEs. The most important of these is E – EVOLVING—if you notice any change in your moles, or any appearance of new moles, mention this to your dermatologist during your check-up. [*Make note that even benign moles can grow. Not all change is melanoma.]

A – ASYMMETRY: if your mole has become uneven or asymmetric, have it looked it.
B – BORDER: benign moles have nice, regular borders. Dangerous moles have irregular borders.
C – COLOR: benign moles usually have only one color. Dangerous moles can have two or more.
D – DIAMETER: benign moles are usually smaller than a pencil eraser (<6mm).
E – EVOLVING: changes in your moles or the appearance of new moles should prompt examination.

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