Category Archives: Medicine

Making Dr. Google Work For You!

Just ask any doctor. You’d be hard pressed to find one who hasn’t had a patient bring in a Google search to discuss their potential diagnoses. Got a rash? Check Google images. Weird dizziness? You might just have vertigo, anemia, pregnancy, a brain tumor, or a bite from a Guatemalan rain spider (okay, I made up that last one). Let’s face it. We live in an Information Age and Google is a brilliant source of information. However, without the medical background with which to put all of these potential causes of illness and disease into perspective, Google can often be a confusing and sometimes frightening place. Doctors and other medical providers are then left to pick up the pieces of this information overload. Not only do we need to spend the precious few moments we have with you providing preventive care and treating disease, but now we also have to help you sort through complex and confusing diagnoses, most of which are highly unlikely, and debunk often faulty information gleaned from chat rooms and non-reputable sites. We providers get frustrated. We gnash our teeth. Our ire rises. We curse Dr. Google under our breath. We buy mugs that say “Please do not confuse your Google search with my medical degree”. But I’m going to let you in on a little secret (and I might just get kicked out of the club for this one). Doctors also use Dr. Google. Gasp! Shock and awe!

Come on… Don’t judge. Google is, hands down, the fastest way to find any information we need. Side effects of Hydralazine? Nomogram for an elevated bilirubin? Algorithm for working up adrenal insufficiency? Just search Google and Bam! Two seconds later and the world of science and medicine is at your fingertips. The difference is, and this is an extremely important difference so listen up, doctors know which sites to rely on as reputable and factual, and which to ignore. Did you get that? Out there, in the Googleverse, there are both good sources of information and bad sources of information. You just have to know which ones to trust.

So today, class, we are going to learn how to differentiate reputable from non reputable sites for gathering accurate and well founded medical information. There are just a few basic tenets you need to know.

1. First, look for nationally recognized sources: The Centers for Disease Control (CDC), the National Institutes of Health (NIH), The Mayo Clinic, The Cleveland Clinic, etc. Government funded, not-for-profit, and university sites tend to be trustworthy.

2. In general, disease specific sites are also reputable: The American Cancer Society, The American Diabetes Association, The Alzheimer’s Association, etc.

3. Medical information is constantly changing so make sure to check the date of the article you are reading or the date of most recent update for the site you are using. Look for the most current sources.

4. Research the author. Are they reputable? Do they have a background which allows them to speak with authority or is this merely an opinion piece made to sound scientific? Do they list their sources backing up their claims and can those sources be verified?

5. If the site is trying to sell you something, be skeptical. As much as possible, you want to look for sources that are non biased and don’t have a conflict of interest. If an online medical practitioner or site is trying to sell you their products, they are inherently biased and you need to move on.

6. Please don’t believe everything you read on Facebook (no offense, Facebook). Just because a friend of your mother’s neighbor swears by an essential oil to cure cancer or is claiming that X vaccine has been linked to infertility or that Y supplement is great for weight loss and is totally safe, doesn’t make it true. Before you start that miracle cure or supplement, please talk to your medical provider. Let them help you make sense of all those claims and help keep you safe and healthy.

Well, that’s about it. It’s pretty simple really. Pick your sources wisely and discuss any questions or concerns you have with your medical provider. And, if something sounds too good to be true, it probably is. Google can be an amazing tool for learning, for patients and doctors alike. But, as with any tool, we just have to know how to use it. We, as medical providers, may grumble a little when the Google search shows up during our office visit but we shouldn’t let it frustrate us so much. Our job is to educate and that is what Google is allowing us to do. After all, the origins of the word “doctor” come from the Latin word “docere” which means “to teach”.

Yep. I looked that up on Google.

 

Flu Vaccine 101

So, I feel like I spend hours and hours every day (this may be a slight exaggeration) talking to people about the flu shot. I guess by this time of year, when we are in the full swing of flu season, people who are already convinced of the vaccine’s importance have gotten it and those that I’m seeing in my clinic who haven’t gotten it are either just late to the game or truly need some talking through the facts and fictions about the flu shot. So, in an effort to get the word out more universally, I am going to distill my flu vaccine counseling down into an easy to digest blog. I hope that you enjoy it, find it informative, and will share it with your friends and family. Please spread the word about this life-saving intervention.

First, a little clarification about the Influenza virus. Every day I get folks telling me that they got the flu shot but that they were “sicker that year than ever before”. The flu shot was never meant to be a one stop shop for preventing illness. There are numerous other viruses out there that can cause a flu-like illness that are not the flu. Here is what true Influenza looks like. It comes on suddenly. One day you’re fine. The next day it feels like you were hit by a truck. Your body hurts. Your eyeballs hurt. You have a high fever, cough, headache, sore throat, and fatigue. It lasts, typically… a week. Unless, of course, you have complications of the flu that may linger longer. Also, the “stomach flu” is NOT the flu. This is a viral stomach bug. Only occasionally does a person with the flu have vomiting (maybe a little more common in kids than adults) and diarrhea is not part of the picture. If you’ve got vomiting and diarrhea, you’ve got something else and the flu shot doesn’t help with that – I wish it did. I HATE vomiting!

Fictions:
1. “The flu shot causes the flu.” This, my friends, is false. The flu shot is a killed virus vaccine and, as such, cannot cause the illness it is meant to protect against. Live attenuated virus vaccines can make those with a suppressed immune system ill but not killed virus vaccines like the flu shot. “But I felt so cruddy after the shot”, you say. It is not uncommon to feel a bit under the weather after the flu shot – or any shot, for that matter. A bit of achiness, mild fatigue, even low grade fever is considered a normal response and is just your body’s immune system kicking into gear. It is NOT the flu. Trust me. The flu is much worse. Scenario #2: It takes 2 weeks before the flu shot even works and it is possible to be exposed to and contract the flu in that 2 weeks when you are not yet protected. This is why it is SO important to get your flu shot in the early fall. That way, by the time we see the flu in the winter months, your immune system is ready for the fight.

2. “The flu shot is not that effective. It won’t help me anyway.” Au contraire, mon frere. Even though the flu shot is the “best guess” for what strains will be circulating that year and is not always spot on, it still protects you from serious complications of the flu. The Northern and Southern Hemisphere flu seasons are exactly opposite of each other. We look to the Southern Hemisphere’s flu season to try to predict what is heading our way. Some years’ guesses are better than others but that doesn’t mean the vaccine is not worth getting. We know this from looking at data regarding people who died from the flu. The Centers for Disease Control (CDC) looked at all of the pediatric deaths during the 2012-2013 flu season and found that 90% of these deaths had been in children not vaccinated for the flu. And, since the flu vaccine was introduced in 1933, we have not seen a flu pandemic such as the 1918 Spanish Flu that killed nearly 50 million people. The flu vaccine works. Moving on.

3. “I’m Healthy. I don’t need a flu shot. I’ll get over it.” Well, maybe. But even healthy people have serious complications from the flu like pneumonia, respiratory failure, and death. It is true that those with chronic illness, the elderly, babies, and pregnant women are at greatest risk. But remember those children who died in 2012-2013 from the flu? 40% of those kids had absolutely NO chronic illness or other risks for serious complications. And so what if you are healthy and you do get over it? What about all of those around you? What about those you come into contact with out in the world? Shouldn’t we try to protect each other and keep each other healthy as well? You. Yes, you. You are contagious for approximately 2 days before you even have one symptom. And there you are, out there in the world touching things, shaking people’s hands, and spreading germs that you don’t even know you have.

4. “I prefer to get my immunity naturally.” Nope. Doesn’t work that way with the flu. The flu strains change each year. Having the flu one year does not prevent you from getting the flu the next year.

Facts:
1. You are more likely to have serious consequences from the flu than from the other infections for which we more readily vaccinate. In 2015 we had our first measles-related death in over a decade. By contrast, the CDC estimates that the average number of influenza-related deaths in the 2011-2012 and 2012-2013 flu seasons ranged from 12,000-56,000 annually in the US (250,000-500,000 worldwide). Statistically speaking, you should absolutely get your flu shot. PS – Please don’t use this as reason not to vaccinate for measles or other infections. Vaccination is the reason we don’t have the number of deaths from these illnesses that we used to have.

2. This year, there are two different circulating strains of the flu. If you had the flu before you had a chance to get the flu shot, you should still get the flu shot to protect you from getting the other strain that is out there.

3. There is NO mercury in the flu shot unless you are getting a vaccine drawn from a multi dose vial. And if you are getting your vaccine from a multi dose vial, the amount in one pediatric dose is equivalent to eating one 3 oz can of tuna fish. Not so scary is it? Also, the type of mercury in that multi dose vial is Ethyl mercury (like my sweet aunt Ethyl, not dangerous at all) which is cleared much more rapidly and is less harmful than Methyl mercury (the kind found more commonly in that can of tuna).

4. Everyone needs a flu shot – to protect themselves and their loved ones and to protect those more vulnerable in our community. The flu shot can be given as early as 6 months of age (at which time the vaccine is actually given in two doses spread apart by a month, after that it is one dose per year).

5. In an ideal world, everyone gets the flu shot by Halloween. But it’s not too late to get the shot now. Flu season typically lasts into the spring, some years running as late as May.

So, please protect yourself and those around you. Get your flu shot. And if you have more questions or concerns… ask your provider. Don’t let misinformation and misunderstandings keep you from being healthy and safe!

A Hidden Epidemic

In my first job out of residency, I worked with another new physician.  Let’s call him Bill.  Bill was a warm, caring and generous, but highly anxious, person. He worried about everything: every patient he took on, every decision he made, every lab that was even remotely out of range.   My partners and I also suspected there were things going on in his personal life that were troubling him but we wanted to remain professional.  We didn’t want to pry or to make him feel uncomfortable.  We figured he was just like many of us… trying to sort out his new role as physician, finding a way to make it fit into his life.  Then one day Bill didn’t show up for work.  We contacted his family, who lived out of state, and they hadn’t heard from him.  Later that day, Bill’s body was discovered in the river.

In our last all provider meeting, we discussed the new regulations requiring health care providers to have a certain number of hours of training regarding suicide.  As the requirements and options for training were being laid out, I couldn’t help but think of Bill and of our medical profession as a whole.  The figures are frightening.  The equivalent of nearly 2-3 medical school classes of physicians die by suicide each year.  Male physicians are about 1.5 times and female physicians about 2.5 times more likely to die by suicide than the average person.  Not only do we need to undergo training for suicide risk detection and prevention for our patients, but, it seems, we desperately need it for ourselves as well.

The role we have chosen for ourselves is difficult.  It has many rewards, of course, but it also can take its toll on self and family.  As a group, we tend to be harder on ourselves than we are on others.  We hold ourselves to sometimes unrealistic and unhealthy standards.  We are excellent at delayed gratification and dedication to others before self.  We want to please and have a hard time saying no.  We put our lives and families and finances on hold to complete our training and to build a practice, only to be met with what sometimes feels like a lack of appreciation for our efforts.  And the ultimate goal of our calling, the development of a close and caring relationship between doctor and patient, is eroded by the seemingly endless administrative duties which are taking over our day-to-day lives.  And if we do ultimately feel like medicine is not the right place for us, we often feel stuck  – without other skills, saddled with huge debt, and lacking time to pursue other options.

We need to begin to care for ourselves as we care for our patients.  We would never suggest that our patients work 60-80 hour weeks, skip meals, get too little sleep, defer family time for more hours at work, take only a few weeks of maternity or paternity leave, etc.  This is not a humane way of living and it is unsustainable.  We need to support each other as coworkers and in an organizational capacity in pursuing quality of life in the workplace and at home.  Our emotions – all of our emotions – are not weaknesses.  They are part of what makes us human.  We need to acknowledge this as a profession and work to get rid of the stigma that surrounds mental health issues in healthcare providers.  And, finally, we need to be there for each other if one of us is struggling.

Some of us worry that reaching out for help would be an admission of weakness or would signal to others an inability to practice in the best interest and safety of our patients.  So we don’t reach out.  Many of us have long office hours and spend more hours after work completing charting and don’t see a time to be able to attend counseling sessions.  So we don’t reach out.  But we have to find a way to break down these barriers to care.  Below are some of the resources available to us that are confidential and will work around our hectic schedules, we just have to be willing to get started.

None of us can travel this road alone.  If you are struggling, please reach out and let someone help you.  After all, wouldn’t you do the same for another in need?

·        The Spokane County Medical Society (SCMS) Foundation offers a Wellness Program which is staffed by psychiatrists who specialize in treating medical professionals.  There is complete privacy and confidentiality (providers are referenced by number only and providers can either choose to go to the psychiatrist’s office or there is a separate room with a separate entrance at the SCMS offices that facilitates anonymity).  For SCMS members, the  1st 8 sessions are free.  Sessions are contracted at lower rates for non-members.  Mental health providers are available 24/7 by pager and can be reached at 509-720-6000 (if not immediately available, a message can be left which the recording states will be returned within 10 minutes).  You can find out more about the SCMS Foundation programs at www.spcms.org.

 

An Open Letter to Mr. Trump and Mr. Kennedy

Dear Mr. Trump and Mr. Kennedy,

Are you serious? I mean, are you really serious – a committee to investigate the effectiveness of vaccines? What do you think science has been doing for the last 220 years? We are going to spend millions of dollars and precious hours that could be better spent, I don’t know, say… working on securing peace in the Middle East or developing a realistic and actionable alternative to the Affordable Care Act (which, by the way, I happen to like and don’t feel needs replacement but, perhaps, improvement). This is ridiculous!

We (I really want to say “you” but I’m trying to be inclusive here) must have an unbelievably short collective memory. Do you not remember smallpox? Do you not remember polio? Do you not remember the Influenza pandemic of 1918, which affected 1/5th of the world’s population and killed more people than died in all of WWI? 50 million people died! That’s million, with an “M”! Why do we not see these horrible plagues anymore? Because of vaccines, that’s why! But, somehow, even though many people – healthy people – still die of the flu every year, this doesn’t feel like a current concern. Maybe it’s not sexy enough of an issue. I would stake my career on the fact that, if there were an Ebola outbreak and people were bleeding out of their eyeballs and dying left and right, every single person out there would stand in line to get a vaccine if one was available. Maybe the flu and other vaccine-preventable diseases just aren’t scary enough.

How pretentious and elitist of us. This move, to question the utility and benefit of vaccinations, is a luxury of the wealthy. You do not see the people of third world countries or those in our own country who are just scraping by, living paycheck to paycheck, questioning the benefit of vaccines. To them, this is a life and death situation. Whether to vaccinate is a make or break decision. For those out there who don’t have access to adequate health care or can’t afford the medication or the doctor bills to treat an illness, having a family member get sick can be catastrophic. They can’t afford to take time off of work to nurse their child or themselves back to health. So, what happens? Kids get sent to school during illness. Adults continue to go to work during illness. And illness spreads.

It feels like I spend half my day trying to convince people to get vaccinated. As a family doctor, who cares for a largely middle to upper middle class patient population, I get a lot of questioning patients. In 2015, after growing frustrations with how much effort was expended addressing this issue, and not feeling fully prepared to answer all the concerns that my patients had, I took the time to do my homework. I took every doubt, every reason that I have heard not to vaccinate, and addressed each one in turn. I wrote an article about it called An Ounce of Prevention and you can read it if you are so inclined, or you can do your own research. You will find, as I did, what we as people of Science and Medicine already knew. Vaccines are safe and vaccines save lives!

What I know to be true in my heart of hearts and what I see to be true in my everyday practice, is that population health and individual health are inseparable. If you choose not to get vaccinated, so be it. You are an adult. But know that your choice puts others at risk. We vaccinate not only to protect ourselves but also to protect the more vulnerable in our community. Or maybe you don’t care about those more vulnerable and at risk individuals.

Make your own personal decisions, but don’t deny the right to this lifesaving health intervention to others and don’t waste our time and dollars setting back the clock to the 1700s.

Sincerely,

Gretchen LaSalle, MD

On the Wrong Side of History

I had expected tears today. I had hoped for tears of joy… tears of love and gratitude for a woman who has given her life’s work to making the world a better place for others. A place where, no matter what color or religion or sexual preference or disability or socioeconomic background you come from, you are given the same rights and privileges and opportunities and responsibilities as everyone else. I had wanted to cry tears of joy for all of the little girls out there who would know that they could grow up to be anything they wanted to be, if they were just willing to work hard enough. I am so grateful to Hillary Clinton for giving us such a wonderful example of what intelligence, hard work, dedication, openness and acceptance, caring, and a life in service to others can mean to so many.

What I cry today, though, are tears of sadness, of shame, of anger, and of frustration. How can this country, people that I love and believe to be intelligent, big-hearted individuals, vote for a man who represents such vitriol and hatred? He has publicly ridiculed people with disabilities, espoused hateful and xenophobic rhetoric, shown blatant disrespect for women, those in our military, and those that are different. How can those people that I love, who have children of their own, whom I presume want to teach values of tolerance, love, and respect of others, how could they vote for this man? What do you tell your children about why you would put such a person in the Whitehouse? I so dearly hope that this man’s talk was just that, talk. That he used the media and talking points to his advantage to gain access to this highest of offices but that his true intentions and actions will not be as divisive and hateful as he presents in his public face to the world.

This election has wreaked havoc on all of us. We have been so polarized. For years I have not wanted to participate in political discussions. I want to love people because of what’s in their hearts and how they treat others, not because of their political leanings. I respect others rights to feel the way they feel and to vote their conscience. But, today, I admit myself disappointed in so many, whose vote for Donald Trump was like a slap in the face. My parents (a heterosexual couple and a lesbian couple) taught me to love everyone, to fight for those who can’t fight for themselves, to care for all people and to devote my life to service.   They taught me that I was smart and good and could do anything I set my mind to and I have taken that message to heart, spending my life as a physician, caring for others. I grew up knowing, deep down in my soul, that love and caring for others is THE most important thing. Love is love no matter what color or gender or religion. We are born knowing only love. We are taught hatred. I fear, America, that we have voted on the wrong side of history today – that we have voted for hate.

Today, I am grieving. I am grieving for my relationships, some of which have suffered because of this election. I am grieving for our children who have to see this superficial, bigoted, misogynistic man as our country’s leader. I am grieving for the immigrant families of this country who are working so hard to make a life for themselves and who will live in fear from this day on. I am grieving for my patients who only recently have been able to get health care, either because of inability to afford it or because of pre-existing conditions. I am grieving for those of color and for those in the LGBT and transgender community, who have fought so hard for equality and acceptance.

My only consolation is that, now that the office of President and the House and Senate are Republican controlled, there will be no one else to blame if change for good doesn’t happen in this country. No more obstructionist tactics. Now they must get to work, proving that their ideas will move us in a better direction. I sincerely hope that they, that we, can be successful together.

Today I will grieve. I will allow myself that. But tomorrow, I will continue to teach my children a message of love for diversity and respect for all. I will go on in service to others and fighting to get my patients the care that they deserve. I will try, every day, to make the world a better place for myself, for my children, and for you and your children. Today I grieve, but tomorrow begins the work of repair and healing and there is a lot of work to be done.

 

Ugh. Vertigo.

I am unfortunately inspired by recent events to write about Benign Positional Vertigo.  May you never suffer it but, if you do, here are some very important things to know.  First, you are not dying.  For the rest, read on.

 

Ugh. Vertigo. Or more accurately, Benign Positional Vertigo – BPV. I would not wish it on my worst enemy. Well, come to think of it, maybe I would. Can you imagine an entire army suddenly overcome with the inability to walk a straight line, falling over left and right, and vomiting if they do anything but stay completely still? Maybe that would be a good tactic to use against your enemy. There you go, US government, a nonlethal defense tactic, offered up by yours truly. Now, all you have to do is figure out a way to induce vertigo.   This may prove difficult, though, as we still don’t know what causes it. There are lots of theories… head trauma, change of altitude, fluid in the inner ear, etc. Get to work and good luck!

I remember my first bout of vertigo very vividly. I rolled over in bed and looked at my clock and it was moving left and right. I tried to sit up and the whole room was spinning. It was as if I had been drinking heavily the night before, with all the repercussions but none of the fun. I tried to walk to the bathroom and fell over. I crawled on my hands and knees to the bathroom where I promptly threw up. But there was no relief after vomiting, like when you have a stomach bug and you feel better after having thrown up. Nope. The room was still spinning and I still felt like death warmed over. The strange thing about vertigo is that, other than all the spinning and the vomiting, you feel totally fine. You are suddenly completely unable to function even though the rest of your body is working well.

You can see why people end up in the emergency room with this condition. It is totally frightening. As a family doctor, I recognized this for what it was. I remembered my teaching on vertigo and was able to match my classic symptoms to that diagnosis. Your average non-medical person, though, has got to think they are dying. And when you go to the ER, especially as an elderly person, with the inability to walk and vision change and vomiting… what are you going to get? You are going to get the million dollar work up, that’s what you are going to get. After all, it could be a stroke or a hemorrhage or a brain tumor.

Luckily, there is a simple test that the doctor can do to tell if this is BPV. Though you, as someone suffering from vertigo, are not going to find it very pleasant. Basically, we lay the person back, turning their head to one side and then the other (This is called the Dix-Hallpike maneuver). In someone suffering from an acute attack of vertigo, this is going to induce the symptoms of spinning and nausea. Not so much fun. But the doctor, in being able to reproduce the symptoms with this maneuver, and in watching your eyes start to move in an atypical rotatory pattern, can diagnose BPV without a huge workup.

Thankfully, there are some pretty easy steps to take to get this to stop. The theory is that there are little cells in the inner ear (you’ll also see them referred to as “rocks” or “crystals”) that are supposed to be aligned a certain way. In BPV, these cells somehow get out of alignment. The treatment, apart from giving you a nausea medicine so you don’t continue to throw up, is to get the cells back into alignment. We do this with a type of physical therapy for your inner ear, called Vestibular Rehab. If you are someone who gets very nauseated with vertigo, you will have to get your anti-nausea medication (we commonly use Meclizine, sold over the counter as LESS DROWSY Dramamine or Bonine) on board first or else you won’t be able to do the therapy exercises. The first time this happens, we usually refer someone to a Vestibular Rehab therapist to demonstrate the maneuvers (called Epley’s Maneuvers) that can then be done at home. It is important to pay attention to what side tends to trigger the symptoms (meaning, when you turn your head to the left or to the right, which side brings your symptoms on the strongest?) as the rehab exercises are geared towards a particular side, left or right. Once you can control the nausea, and put yourself through rounds of these exercises, you will be able to stop the vertigo episode in its tracks. Afterwards, you may be left feeling a little bit off balance. We recommend that you don’t lie flat or let yourself turn to your affected side during sleep for a week after one of these episodes, so as not to allow recurrence.

As a sufferer of vertigo, I can tell you that these exercises work and you don’t have to wait for a full-blown episode to do them. Vertigo can recur so, if you start to get a sense that trouble is brewing, you can put yourself through your exercises before you even get a severe case of spinning and nausea.   My advice – keep the exercises and some meclizine in your nightstand (I even carry meclizine in my purse so it is with me at all times). You never know when one of these episodes is going to hit. Don’t suffer needlessly. These episodes, left untreated, can last many days – many days in which you are completely incapacitated. Learn the exercises and do them. Trust me. You will thank me later!

Disclaimer:

Don’t diagnose yourself! The first time this happens, a medical professional should see you for proper diagnosis. BPV presents fairly classically, but there are much more serious conditions that can present similarly so get checked out!

The Super Talents of Doctor Mom!!!

Able to nurse one cup of coffee for an entire day.

Able to sleep in uncomfortable positions at any time or place.

Able to work terms like “aortic aneurysm” and “poop” into the same sentence.

Able to help the kids with their “new math” while simultaneously calculating days to next refill for Oxycodone.

Able to cheer on her little soccer player (“Great job, buddy!”) and keep her other kids from losing life and limb (“Get down from there this instant!”) while taking weekend call (“No, not you Mrs. Jones.  Yes, you may be having a heart attack.  Please call 911 and go to the ER immediately.”)

Able to defer all bodily functions until patients and children are taken care of and then…

Able to find peace and solitude behind any locked bathroom door.