Monday, March 19, 2018

Can't (cough) Stop (cough) COUGHING?

COUGHS often seem to hang around FOREVER, and this year's flu season has been a prime culprit.
Allergies certainly can cause coughs as well, but typically allergy coughs are more the dry, annoying, clear-your-throat variety, rather than the wet sounding coughing fits (that worsen every evening and prevent sleep) which come from viral respiratory infections. Typically there are a few days of headaches, fever, body aches, sore throats and stuffy nose,  but then the cough itself may persist for up to SIX WEEKS after the initial illness.

Is there anything that can be done for a cough that wont go away? Yes, absolutely.

Will an antibiotic fix a cough? Especially is there is green mucus? Probably NOT, because the vast majority of respiratory infections are viral. Green mucus does not equal bacterial infection.

So you NEVER need an antibiotic for a cough? No, that is not true- sometimes a cough IS being caused by a bacterial infection (possibly a pneumonia), but this is the exception, not the rule.  If you are a week into your symptoms, slowly getting better, and then suddenly you feel a ton worse and develop a fever, this might be a bacterial infection setting up shop AFTER the virus cleared the way past your body's defenses. For this scenario, yes, you need an antibiotic.

If antibiotics don't help, why see your doctor for a cough? 
Certainly not every cough NEEDS to be evaluated by a physician. Over-the-counter cough products include DM (dextromethorphan) (which works at the brain level, decreasing the drive to cough) plus expectorants like guaifenisen (ex. trade name Mucinex) to thin up the mucus. Combinations of these ingredients (along with decongestants to help stuffy noses) make up the cough/cold/flu products like Dayquil/Nyquil/Robitussin/etc. and may be helpful in alleviating cough and cold symptoms in adults.

Cool mist humidifiers next to the bed often bring relief, and honey (either taken as a straight teaspoon or in a hot tea) has been objectively shown to help improve coughs (though never for children younger than one year).

However, often after a viral respiratory infection, the lungs' defenses become overly reactive, creating too much mucus and then subsequent spasm of the airways- we call this "reactive airway disease" and this is the same process we see with asthma. Subsequently, persistent coughs often resolve more quickly when treated with prescription asthma inhalers or other oral medications (possibly anti-inflammatory steroids).

Additionally, there are other prescription cough medications that might help.
Benzonatate (trade name Tessalon) is a non-addictive, non-sedating medication that works in the lungs to decrease the cough reflex by numbing the stretch receptors in the respiratory tract. (In my clinical experience, this drug either works like a dream or has little impact, but its low side effect profile makes it an attractive choice.)

Finally, a cough that is keeping you (and/or your bed partner) up all night despite OTC medications may require a sedating prescription cough syrup. With our current opioid crisis, know that conscientious physicians are appropriately limiting the quantities of these potentially addictive medications, and this is not a long term solution.

Finally,  a cough may come from other sources, such as acid reflux or sinus drainage or a medication side effect (such as from one class of blood pressure medications), which require different treatments.

BOTTOM LINE: See your doctor to evaluate coughs that get worse after a respiratory illness, or that wont go away- please don't expect antibiotics, but know there are other treatment options.

Wednesday, March 14, 2018

Ever been skiing and noticed your toenail had turned black and incredibly painful at the end of the day? Was the entire nail black or only the base?  "Skier's toe" is a common and often very frustrating injury from skiing.

The medical term is a subungual hematoma, which simply means bleeding under the nail. This can occur from a single instance of trauma like dropping something on your toe, or from small, repetitive trauma like a too-small or too-big ski boot (which allows your foot to slip back and forth, slamming your toes repeatedly).

If YOUR toenail is black and painful at the end of your ski day- do NOT wait to go in to a clinic, because the sooner you get treatment, the higher the success rate. The treatment procedure involves burning a tiny hole through the nail, which allows the trapped blood to drain. There is typically only a few drops of blood, but the pain that small amount of blood causes underneath the nail (if NOT removed) is fairly intense.

As with so many medical problems, PREVENTION is key! Make sure your ski boots fit properly- do NOT cram your foot into a friend's boots- and be sure your socks are not bunched up. Using the newer thin ski socks, rather than old school super thick ones, also helps. (Don't worry, the new fabrics keep your toes warmer, despite what it might appear.) This painful injury should NOT occur if your shoes/boots fit correctly.

BOTTOM LINE: Make sure your ski boots and socks fit properly to avoid getting skier's toe!

PS. While in experienced hands, the red-hot tip of a flame-sterilized paperclip may be used to swiftly burn a tiny hole through the nail, I would definitely NOT recommend trying this on your own after watching a youtube video for training. Among other challenges, people have been known to pass out from simply watching this procedure done...and dealing with the head injury (or other trauma) that results from someone passing out (often in a bathroom with sharp or hard counter edges) is worse than the original problem.

Saturday, March 10, 2018

Spring Break 2018: Know Your Limit

Spring Break is here, and students everywhere are gearing up for a week-long party. ALCOHOL is typically a focus of these festivities, so let's review some facts about alcohol dangers. In recent years, studies show that about a third of college students admit to binge drinking (consuming 5 or more drinks in a row.) The good news is that this number is down over 15% from over the last two decades, and actually, drinking trends in ALL categories are decreasing- whether the measurement is annual consumption, monthly, weekly or number of binging episodes. A great tool to educate yourself (or your favorite college student) is this VIRTUAL BAR  where you can enter in your gender, age and weight, and then "pour" yourself drinks and watch your blood alcohol levels rise...

Another wonderfully informative program/website is Aware Awake Alive. Check out their table with drinks/blood alcohol concentrations, and SHARE THIS WITH YOUR FRIENDS. Ultimately, know that if you have a THIRD drink, you are most likely legally drunk. AND, please note, this is a third drink measured by the book (not a "college pour" of alcohol into a plastic red cup- those cups hold several servings in just one glass). The biggest mistake friends make is leaving their intoxicated friends alone to "sleep it off".  If someone has "passed out," they NEED supervision. The alcohol level in their bloodstream will continue to rise, which can cause them to either vomit (and potentially choke, because their gag reflex is dulled by the alcohol) or to stop breathing. If their breathing is less than 8 breaths/minute, CALL 911 immediately.

Pain killers often find their way to spring break as well, whether that is courtesy of a knee injury skiing, or simply part of someone's personal medicine cabinet. Please take note:

Pain Killers (narcotics- think codeine or vicodin) + ALCOHOL= DEATH.

This combination accounts for far too many accidental suicides per year- NEVER MIX THESE.

BOTTOM LINE: Enjoy spring break, but if your festivities include alcohol, make sure you know your limit AND know exactly what to do if one of your friends drinks too much. 

Thursday, March 1, 2018

Altitude Matters!

Skiing for spring break? Whether you prefer downhill or cross country skiing, remember that the high altitude might add in a few medical challenges. Be aware of signs and symptoms of "mountain sickness" (aka. altitude sickness) and if you are susceptible to this issue, look closely at ski resort ALTITUDES. Full disclosure, my destination of choice is Crested Butte, CO, which is one of the higher pun intended.

HOW HIGH do you have to be for altitude sickness?
There is not a set elevation for typical mountain vacations that affects everyone. Symptoms are uncommon at altitudes below 5000 feet above sea level, and fairly common above 8000 feet. If you fly to a higher elevation (such as above 8000 feet), wait a day to acclimate before you start hiking the high peaks nearby. This is very common- an estimated 75% of people visiting mountains with altitudes higher than 10,000 feet will get some degree of altitude sickness. Note that many people have a significant difference in degree of symptoms between altitudes of 9000-13,000 feet- which may explain why they "felt fine" skiing last year at a different resort.

For Colorado skiers: 
The highest ski mountains are in Arapahoe Basin and Loveland (13K), with Breckenridge barely under at 12,993'. Snowmass/Aspen, Keystone and Copper Mtns peak at roughly 12,300-12,500', with Crested Butte and Winter Park closer to 12K. Vail is 11,500 while Durango and Steamboat are around 10, 500. To get below 10K, consider Buttermilk at Aspen (max 9900) or Steamboat Springs Howelsen Ski Area at only 7,136. Obviously the ski towns themselves are not at these peak mountain summit heights, and many resorts offer lodging at a variety of elevations- consider this factor when deciding about the convenience of ski in, ski out, as sometimes you are better off further down the mountain.

When does altitude sickness begin?
Symptoms usually start within the first 24 hours, and often as early as the first few hours after arrival.

What are the common signs?
  • Mild to moderate: HEADACHE, decreased appetite or nausea, insomnia, and lightheadedness
  • Severe:  All of the above plus vomiting and shortness of breath
  • Note that in severe forms, there can be brain swelling (High Altitude Cerebral Edema) and/or fluid collecting in the lungs (High Altitude Pulmonary Edema)- these are medical emergencies.

Ultimately, GOING TO A LOWER ELEVATION will relieve symptoms, but rest and hydration usually alleviate most mild symptoms at your current elevation. For persistent or worsening symptoms, head to a clinic for possible oxygen and medications. In Colorado, there are oxygen bars and even over-the-counter oxygen cans that can help relieve mild symptoms. For insomnia, try over the counter melatonin.

  • Increased hydration with water or sports drinks, and avoidance of diuretics like CAFFEINE and ALCOHOL, especially the first few days.
  • SLOW ASCENT if possible (driving up to the mountains is lower risk than flying).
  • If you have had altitude sickness previously, especially if it has occurred on multiple trips to the same elevation, see your doctor and consider prophylactic medications (acetazolamide or steroids).

BOTTOM LINE: Don't let the mountains literally take your breath away- plan ahead to prevent altitude sickness!

Thursday, February 8, 2018

Flu Tests 101

Positive Rapid Flu Test for Type A Influenza    (C is Control)

Flu season is in full force. If you have high fevers, intense headaches, screaming muscles, razor blade throat pain and/or a wicked cough, should you go get a flu test? How reliable are these rapid tests anyway?

Let's cut to the chase: if you have flu symptoms and a POSITIVE rapid flu test (from a swab lovingly probed up inside your nose), YOU HAVE INFLUENZA. These positive tests are extremely accurate- typically 98-99%.  This means they are very SPECIFIC tests- if the test says you have flu, there is a 98% chance that you really do have the flu, so the likelihood of a false positive is very low.

HOWEVER, if you have flu symptoms and your rapid flu test result is NEGATIVE, you might still have the flu...and your doctor should rely on her clinical judgement. Why? Because these rapid flu tests are very SPECIFIC, but much less SENSITIVE. Sensitivity reflects the percentage of the time that the test is positive when the disease is actually there. Rapid Influenza Diagnostic Tests (RIDTs) average a sensitivity of about 62%, meaning the test turns positive 62% of the time in someone who is truly infected. Rephrased, up to one third of the time when a person has the flu, the test could miss it. Newer digital immunoassays (DIAs), and rapid nucleic acid amplification tests (NAATs) may have significantly higher sensitivities (as noted in this 2017 Systematic Review) but for now these tests have a lower share of the market, and many current studies are industry backed. Meanwhile, most of us in primary care have the less sensitive RIDTs in our practice, which are still quite clinically useful.

Why do doctors even use these tests if they are not super sensitive? Because it affects our treatment plan. If we have confirmation that someone has the flu (with a positive test), then we can feel more confident in NOT prescribing an antibiotic, and limit our conversation to pros/cons of taking an antiviral medication as well as medications for symptomatic relief. This step greatly reduces unnecessary antibiotics, which is critical in an era of increasing antibiotic resistance.
Additionally, knowing a patient definitely has the flu helps us advise them about returning to work/school/activities, since we know flu stays infectious for up to a WEEK. (So STAY HOME at least several days, AND if you have fever, wait until you are fever-free for at least 24 hours without taking tylenol or advil!)

If you had the flu vaccine, will that affect your rapid flu test?  No*. 

(*In prior years when the nasal spray flu vaccine was recommended, there was a chance that you could have a false positive test. Studies have shown that in the first several days after receiving the nose spray vaccine, people may test positive for the flu (even though they are not infected.)

Who should be treated with SUSPECTED illness?The CDC encourages doctors to treat all high risk individuals with suspected flu with antiviral medications. Who is "high risk": anyone hospitalized, patients in nursing homes, and people with immune problems, significant chronic problems (lung or heart disease, for example) or with severe illness such as pneumonia. However, HIGH RISK also includes all otherwise healthy children under the age of two years,  adults over the age of 65, and women who are pregnant or have just delivered their baby within the past two weeks. There are also other less common subgroups that are high risk such as people who are very obese (BMI >40), American Indians or Alaska natives, and youth under 19 who are on chronic aspirin therapy.

Who should be treated with CONFIRMED illness? 
Anyone in the high risk categories above should be treated with antiviral medications if they have a positive test, because treatment definitely decreases severe complications, hospitalization and even death.

Otherwise healthy, active adults who test positive for the flu should have a discussion with their physician about taking the antiviral medications. When taken within 48 hours of the onset of flu symptoms, these drugs have been shown to decrease the duration of the flu by one or two days...which may make a big difference to a student, parent or employee. However, these medications are not without side effects, and for some people, they may aggravate flu symptoms- particularly nausea. In controlled studies, the antiviral medications only cause about 10% more nausea/headaches/fatigue than placebo, but there is no doubt that in a minority of patients, the medicine causes more side effects than they are worth. However, since you have the FLU when you are taking the medications- you already likely HAVE nausea, headache, fatigue, etc- so it is often difficult to sort out. In my family, half of us can tolerate the antiviral medications with zero problems, and half...barely keep the pills down long enough to know.

BOTTOM LINE: If you have flu symptoms, get to the doctor as soon as possible (especially if you would consider taking antiviral medications), and understand that a positive test is REALLY positive, but a negative test does not definitely rule out the possibility of the flu. 

AND...that ounce of prevention...remember to GET YOUR FLU SHOT NOW to reduce your chance of getting the flu (or to at least minimize your symptoms if you do catch it.)

Thursday, January 18, 2018

Starting to Exercise? Time for SOLE Searching!

If your New Year's Resolutions include an exercise program, START by taking a close look at the BOTTOM of your shoes. If they look like mine in the picture above, get thee to a shoe store before you get moving with your walking/jogging/running plan. Note the smooth areas (not to mention the circular area trying to be an actual hole)- that means I have completely lost the tread and traction in that area. 

Are new, good quality running shoes necessary? YES. After two decades of private practice (and seeing hurt knees, hips and ankles that might have been prevented with proper fitting footwear), my mantra is "yes, new shoes may be expensive, but NEW SHOES are cheaper than NEW KNEES."

If you are walking or jogging regularly for exercise, odds are good that you should be replacing your shoes every six months...even though the "shoe still fits"- meaning you have no foot pain, and the tops may even look "practically brand new". 

BOTTOM LINE: Look deep into your "soles" to see if it is time for new shoes! 

PS. I strongly encourage you to head to a local running shoe store with experienced and knowledgable sales people to be properly fitted for shoes. They should not only measure your foot, but watch you walk/run/jog to help advise you on your shoes. Locally here in Austin, I recommend Ready to Run.

Tuesday, January 9, 2018

2018 SIMPLE Doctor Approved Master Cleanse

Happy New Year and Welcome to 2018! 

This year, my theme is SIMPLE. Attention spans are decreasing as fast as our waistlines are increasing (coincidence? Hmm). With tongue firmly planted in cheek, I'm putting everything in my life on a "diet"- or at least a simplification plan, from our overflowing garage and closets, to medicine cabinets, to e-mail in-boxes, to my blog word count, and yes, my own body. Like many, I happily over-indulged in treats, sweets and celebratory liquid calories during the holidays, but now it's time to face the scale, own the numbers and get to work.

How do I kick start my own weight loss program? 

Dr. Grimes' Master Supreme Cleansing 3-Day Detox Diet*:

SIMPLY PUT: Drink water, and eat fruits, vegetables, and a protein source at every meal.

Yep, that's it. Processed foods are eliminated. This "cleanse" is automatically gluten-free and dairy-free (which helps those with undiagnosed celiac disease or lactose intolerance).  Skip everything with high fructose corn syrup and additives or chemicals you can't pronounce. Skip carbonation, caffeine and alcohol. Yes. Those are extras our body does not need. If you are going to get a caffeine-withdrawal headache, keep one cup of coffee but drink it plain- no sugar, cream, etc. Feel free to add a lemon, lime or orange wedge to your water if you want flavor. Please skip sugar substitutes (aspartame, etc.) We are going for a "cleanse" here!

What counts as a protein source?
  •  Eggs, fish, nuts, beans or lean meat
Can you cook them?
  • Absolutely! This is not a "raw food" diet, but a simplified diet. Feel free to use olive oil (one to two tablespoons should be enough per meal), salt, pepper, or herbs to season and cook the protein or veggies. 
How much should you eat?
  • Limit your protein to a serving roughly the size of your expanded, cupped hand (at each meal)
  • Fruits and vegetables? No maximum, but a minimum of two servings per meal (a handful is one serving.)
How often?
  •  Eat four meals: (essentially breakfast, lunch, afternoon snack and dinner.)
  •  Make sure your first meal is within an hour of waking up.
How much water?
  • One large glass with each meal, and any time you are thirsty (no maximum)
*Despite the tongue-in-cheek Master cleanse name, there is nothing special or magical about this recipe. Does it work? Well, yes- it does. It "works" to help you realize what your body needs, versus what your mouth, eyes or mind want. For those with lactose intolerance or celiac disease, this often "works" to improve bowel/abdominal bloating and discomfort. For those trying to focus on better nutrition and weight loss, this frequently "works" as a great jump start. Can you modify this and use yogurt as a protein source? Certainly! The point here is to spend a few days with simple eating and no extra..."extras". Wishing you good luck and great health in 2018!

Bottom Line: If you're looking to "cleanse" your body for a few days, keep it SIMPLE and stick to water, fruits, veggies, and simple proteins (eggs, beans or meat) for a healthy jump start!