Shades of Black and White: Skier's Toe (Nail)

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 (so your foot slams back and forth) ski boot.

If this happens to you- do NOT wait to go in to a clinic, because the success rate in fixing this problem is much higher the earlier it is treated. 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, 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- don't 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, and avoid getting skier's toe!

PS. In prior blog posts regarding this injury, people have commented about home remedies. 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. Among other challenges, people have been known to pass out from simply watching this procedure done on another person's toe...

Check Your ALTITUDE!

Going skiing for winter break? Whether you prefer downhill or cross country skiing, please 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 resorts...no 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.

Treatment?

Ultimately, going to a lower elevation will relieve symptoms, but rest and hydration will alleviate most mild symptoms. For persistent or worsening symptoms, head to a clinic for possible oxygen and medications. For mild insomnia, try over the counter melatonin.

PREVENTION:

• 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!

Wait, Is It Broken?

Image B. Rushing

"I can move it, so it's clearly not broken..." Maybe, maybe not! In primary care settings, the majority of fractures that we treat are diagnosed days after they occur (sometimes weeks), ignored because of this inaccurate belief. Wrist fractures are notorious for this presentation, because often there is not dramatic bruising or deformity, and swelling may not be impressive. Finger, foot, and ankle fractures tend to have much more impressive dark bruising and swelling, but even with these injuries, the affected area can most frequently still be moved voluntarily (albeit with significant discomfort).

Fractures come in many shapes and sizes. Fortunately, most fractures are not "open", meaning most have no break in the skin (no bones sticking out anywhere). Some fractures are simple a hairline crack or a small buckle in the bone, while others break all the way through the bone and may shift out of place under the skin. The only way to be certain whether or not there is a fracture is with imaging- most commonly an ordinary X-ray.

What should you do if you think you may have broken a bone? Is it an emergency? If it is "open" (bone sticking out), of course this is an emergency, and this most likely would have occurred in a very traumatic situation such as a car wreck or other high speed injury. Call 911. If the limb is obviously distorted, or there is new and persistent numbness, tingling or decreased circulation (area turning cold, pale and/or blue), you need immediate medical help.  In less traumatic situations- you smash your toe against a door walking to the bathroom at night, you step off a curb funny, you fall on an outstretched hand- your injury may be urgent, but not emergent. Follow the RICE pneumonic- Rest, Ice, Compression (ace wrap) and Elevation while you are waiting for medical care.

BOTTOM LINE: Voluntary movement of a finger, toe, hand, foot or leg does NOT mean a bone is definitely not broken- head to your doctor if you are having persistent pain, swelling or bruising, and find out for sure.

STDs- The "Underestimated Opponent"

The CDC recently released the 2015 National Overview of Sexually Transmitted Diseases, and the rising numbers are disturbing. The CDC's forward begins by very accurately labeling STDs as a long-standing "underestimated opponent in the public health battle". We CANNOT continue to ignore sexually transmitted infections and assume it is "those people over there" and not OUR crowd who gets these infections! While ZIKA VIRUS has definitely opened up more non-judgmental discussions about STDs, we have a long way to go. Here are a few highlights from the report:

• CHLAMYDIA, the most common bacterial STD, has increased it's rate by 5.9% from 2014, with over 1.5 MILLION cases reported (and an estimated 3 MILLION actual cases), including 645.5 cases per 100,000 females, and 305.2 cases per 100,000 males. Simplified testing (with urine samples rather than only pelvic exams, for example) have increased the number of people tested, so yes that explains some increase, but the overall number is still...huge. And why do we care? Because undiagnosed and untreated chlamydia infection can lead to chronic pelvic pain, more serious infection (PID-Pelvic Inflammatory Disease), and even infertility. The vast majority of chlamydia infections are SILENT, so if you don't think you are "at risk" so you don't get screened, you will not know you have it. Between 10-30% of untreated chlamydia infections progress to PID, and 10-20% of those cause infertility. Think of the emotional, physical and financial burden that could be eased...if people simply were tested routinely, so diagnosed and treated. 

• GONORRHEA, another bacterial STD, was on track to be eliminated back in 2009, but we are going the wrong direction now with a rate increase of 12.8% AND increased drug resistance. We literally only have ONE recommended treatment now for gonorrhea (a combination of an injection of ceftriaxone and an oral dose of azithromycin) and resistance is growing. How many actual cases? Not the 1.5 MILLION reported number like chlamydia, but approaching a half million at 395, 216 cases. And once again, this is only the number reported. More disease + less cure = SCARY. Untreated gonorrhea, like untreated chlamydia, can cause chronic pelvic pain, PID, and infertility, not to mention spreading throughout the body to joints, the heart and the brain (meningitis).

• SYPHILIS is far less common that Chlamydia or Gonorrhea, with a bit less than 24,000 cases in 2015, but unfortunately this disease is rising as well, and sadly there were still 487 babies born with congenital syphilis last year.

These three STDs can be detected and treated successfully IF sexually active people will get tested regularly, but we have to improve our education and social dialogue so everyone understands that sexually transmitted diseases are underestimated on a personal basis, because we still think you can tell what "sort" of person would have these infections.

Bottom Line: If you are sexually active with a new partner, then you are that "sort" of person that could have an STD- because we ALL are, regardless of income, social status, religious beliefs or gender preferences. GET TESTED!! (And expect your partner to do the same.)

ZIKA's Unexpected Gifts

In no way do I want to minimize the serious complications of Zika. However, the media buzz surrounding Zika offers an unexpected gift- effective STI (sexually transmitted infection) education. What is Zika doing that AIDS did not?

·      Zika normalizes TALKING about STIs

Zika arrived as the newest “malaria”- a mosquito-borne illness, with the added threat of potentially devastating consequences in pregnant women. Like familiar flu season reports, headlines track Zika’s progress across geographical borders, firmly establishing Zika as a hot topic. Pictures of infants with birth defects tug at our hearts, while reporters jockey to broadcast the latest Zika developments. And then, BOOM- when health experts discovered that Zika could also be transmitted sexually...the conversation automatically extended to include condom usage and medically recommended abstinence. Zika fortunately lacks the “yuck” factor (and visual images) that shove other STIs out of well-mannered conversations, so the buzz continues.

·      Zika clearly shows ANYONE can get an STI

HIV/AIDS pointed a national spotlight on STIs, but that light was sharply focused on subpopulations at the highest risk- homosexual males, sex workers and IV drug users. The greatest myth is that STIs only occur “over there, in those people” (translation- not MY peers). After twenty years of private practice in an educated, affluent community, I can assure you that sexually transmitted infections also occur commonly in college students, soccer moms (and dads), and successful professionals who fit none of the traditional “high risk” subgroups. (Curious? Check out Seductive Delusions: how everyday people catch STIs for a sneak peak behind exam room doors.)

·      Zika, like most STDs, is often SILENT.

Zika may cause mild to severe symptoms including fever, rash, headache, painful joints and irritated eyes. In pregnant women, Zika can cause birth defects.  But Zika often causes no symptoms at all, which means infected people may have no idea they are carrying a disease that they can pass on to another person- which is the scariest truth about ALL sexually transmitted infections. For example, chlamydia, the most common bacterial STD, causes either very transient or no symptoms the vast majority of the time (90% in males, and at least 70% in females), yet if not diagnosed and treated, can lead to chronic pelvic pain and even infertility. Take home lesson?  “No symptoms” does NOT equal “no disease”. Get tested. Ask your partner to get tested.

·      PREVENTION is better than CURE

For Zika, prevention is all we have. Travel advisories, environmental pest control, and personal insect repellent target mosquito transmission. Consistent condom use for all types of sexual intimacy (oral, vaginal and anal sex) decreases the transmission every STI, including Zika. Effective vaccines extend our STI prevention for hepatitis B and HPV, and anti-viral medications help decrease transmission of herpes and HIV. While antibiotics can cure bacterial disease, they cannot undo damage already caused by long-standing untreated infections. Treatment is good, but prevention is better.

BOTTOM LINE:  Thank you, Zika, for expanding and normalizing discussions about sexually transmitted infections, and reminding us that the only way to know if you or a potential partner is carrying a silent infection is to GET TESTED- and START TALKING.

*This post was first published in the Johns Hopkins University Press Blog

No BULL...Get Your FLU SHOT!

Yes, it's only September, but we've been seeing cases of the flu all month! Today the University of Texas kicked off our 2016 flu shot campaign, and happily, students were lined up and ready to go. Our staff does a wonderful job of efficiently providing vaccines for students, faculty and staff- Hook 'em! The vaccines are widely available now, in your doctor's office, pharmacies and even grocery stores.

WHO: EVERYONE that is 6 months old & up (*with rare exceptions*)

WHY: THOUSANDS of people die from flu every year, here in the United States- between 3000-49,000 deaths. Hundreds of thousands are hospitalized, and many millions seek care with their own doctors, costing our healthcare system over $10 BILLION each year for direct flu-related costs. Closer to home- how many days can YOU (or your kids) afford to stay home sick or try to function with miserable flu symptoms?

The flu vaccine is not perfect, since new strains emerge each year and scientists are not yet clairvoyant. If you get the vaccine, you MIGHT still get the flu- but your illness should be much milder than if you were not vaccinated. Flu vaccines do NOT cause the flu- repeat- DO NOT CAUSE THE FLU. Note that influenza is not the same as the many viruses that cause "cold" symptoms, so the flu vaccine does not protect you against getting EVERY sore throat, runny nose, cough, sneeze and fever.

What's new for the 2016-2017 flu season?

• ONLY INJECTABLE VACCINES this year (NO nasal spray)
•  the nasal spray one with attenuated live virus will not be offered because last season's data has shown it to be significantly less effective than the injectable ones
• RECOMMENDATIONS for the 1.3% of children and 0.2% of adults with EGG ALLERGIES
• If your egg allergy means you get only hives after eating eggs, you may receive either type of vaccine available
• If you have a more severe egg allergy beyond hives (lip swelling, trouble breathing, passing out or vomiting), you may still receive either vaccine but it should be done in a medical setting with providers trained and able to manage severe allergic reactions.

BOTTOM LINE: Flu season is here once again. I got my flu vaccine last week- have you had yours?

Can College Students Get Ulcers?

"Does STRESS cause stomach ulcers?"

In a college health center, this is a question I hear fairly often, especially around midterms or finals. Certainly most of us have experienced stomach discomfort when we are anxious- whether that is nausea, cramping, diarrhea or pain- but the vast majority of people with those symptoms do not have actual ulcers.

However, people who are stressed may have COPING HABITS that can irritate the stomach lining, causing a gastritis (inflammation of the stomach lining) which might facilitate the development of ulcers:

• Drinking too much alcohol (more than one drink/day for women, or more than 2 drinks/day for men) 
• Using too many NSAIDs (Non Steroid Anti Inflammatory Drugs) like ibuprofen (aka. Advil/Motrin/etc).

Of course, college football weekends with prolonged tailgating and subsequent hangovers (treated with ibuprofen) are the perfect set up before "stress" from midterms is even a factor.

Stomach ulcers, meaning an abrasion or "ulceration" in the inside lining of your stomach, are actually primarily caused by a bacteria called H. pylori, which lives in the GI tracts of approximately 30-40% of Americans. It may be present for decades before it causes any symptoms. This bacteria is identified within 70-95% of ulcers that are biopsied in the stomach and the first part of the small intestine, the duodenum.

What are symptoms of stomach ulcers?
The discomfort of ulcers starts off feeling like hunger to many people- a deep ache, located below your breastbone and above your belly button. The pains may come and go at first, and may also be associated with feeling nauseated or bloated after meals. Initially, taking an antacid such as TUMS will relieve this sensation. The timing of the pains tends to vary with the location of the ulcer, and the pains might come and go for weeks at a time.

How does a doctor check for ulcers?
For young people (under 55 years) who are otherwise healthy, the current standard of care is to test for the presence of H. pylori bacteria, and treat immediately if that is positive. There are blood tests, breath tests and stool tests available. For older patients or those with risk factors for stomach cancer, direct visualization with endoscopy is recommended to allow the doctor to biopsy any suspicious areas.

How are ulcers treated?
If your doctor finds H.pylori, you will be treated with not one, but several medications: one acid blocking medication called a proton pump inhibitor, and two antibiotics. There are different regimens, but all include at least these medications at different dosages and timing.

If it's not an ulcer, what else could it be?
Persistent, recurrent upper abdominal pain and nausea could multiple other medical issues, including (but not limited to) gall stones, pancreatitis, hernias, colon disease (including celiac or inflammatory diseases like Crohn's) or other systemic illness. The key point here is not to worry you, but to encourage you not to suffer in silence. Avoid the temptation to self-diagnose or to try every over-the-counter remedy before heading in to see your family physician.

BOTTOM LINE: If you are having recurrent pain in your upper abdomen, nausea, bloating or other discomfort, stop taking NSAIDS and drinking alcohol, and head in to see your doctor. 

6 Tips for Freshmen Insomnia

Freshmen college students have many challenges as they adjust to their new environments, and sleepless nights in dorm rooms can trigger a downward spiral of fatigue, trouble concentrating, and poor grades...which leads to anxiety and more difficulty sleeping. What can students do to try and stop this cycle? Certainly there are multiple causes for insomnia, from roommate noise to seasonal allergies, to homesickness or academic stressors, but here are six basic steps to try first:

1. CONSISTENT SLEEP (& WAKE) TIMES- with MWF and T/Th schedules, often students have drastically different sleep and wake times each day, which doesn't jive with our body's internal clock. Getting up and going to bed at consistent times (within an hour's window) will help set your body on a schedule. Create a morning library study period for yourself on later start days that you treat as another class, or commit to an early exercise class.* (Daily aerobic exercise is a wonderful stress reducer, but because of the adrenaline it produces, make sure not to exercise within three hours of your normal bedtime.)
2. SLEEPING MASK- this is a great way to physically block out light in a shared space. Spend the extra few bucks for one that fits right, is easily washable and comfortable (usually around $15-$20). Side note- keep the mask ON during the night...resist the temptation to check the time. If you can't cover your eyes, cover the CLOCK. Our brains are clever, and can consistently wake us up at the exact time every night if we allow ourselves to look at the clock. 
3. BLOCK the NEW NOISE- like snoring roommates, hallway traffic or loud face-timing neighbors- with a combination of comfortable ear plugs or extra white noise from a portable fan (even if you have A/C). 
4.  GUIDED MEDITATION APP: consider one from Healthline's "Best Meditation Apps of 2016"
5. AVOID SCREENS at least the last hour or two before bed. Numerous studies have confirmed the detrimental affect of blue lights on sleep cycles. Students live on screens both socially and academically, so this is a tough one, but simple modifications include saving your actual book reading or off-screen math assignments for the end of your study evening, and taking your showers at night. And...not playing games or stalking social media as your "relaxation" time when you get in to bed. 
6. GO TO TUTORING. If academic stress is the primary source of your anxiety and subsequent insomnia, do not suffer in silence or wait till you "have" to talk to your professor! Almost everyone is initially overwhelmed by the volume and intensity of college courses, especially if you got in to your "dream" school. Learning to utilize study partners or groups, attending tutoring sessions, and discovering new interactive memorization techniques will help dramatically. Locking yourself in a room "until I finish", skipping fun activities as you try to force-feed yourself the information will be minimally productive, if at all. Alternating study locations, prioritizing sleep, and taking practice tests will improve your grades. All-nighters do not. 

BOTTOM LINE: College life is tough on sleep cycles- try these steps to start improving your chances of restful sleep, so your brain has the energy and focus to succeed!

College Student Essential: the Medication Box

August has arrived, which means panic is setting in for many families as they pack up their high school graduate and send them off to college. Pinterest-driven dorm room cuteness shifts much of the focus (at least for girls) to inspirational quotes, picture displays and twinkling lights.  Mothers alternate between doing everything for their "baby" one last time, to cramming in last minute instructions on washing clothes and paying attention to car maintenance. If your child takes any medications on a regular basis (prescription or not), then I would like to add one or twoVERY important items to your college shopping list:

• Weekly medication dispenser 
• Medication lock box

Why do kids need an "old person's" medication box? The same reason that birth control pills come labeled by the day! Taking medications can be so routine that we often do not pay full attention to what we are doing as we pop in the daily antihistamine (or vitamin, or whatever). How many times have you finished brushing your teeth, then wondered- wait, did I take my pill yet? If your pills are in a day-labeled container, you have your answer. If they are in a bottle...you have to guess. This is particularly an issue for freshmen college students, because in many households, parents set out the medications each morning with breakfast...which means that students who have not been in charge of their own medications have not had to create this habit on their own. I regularly see young people who are having side effects because they accidentally took their ADD medication twice in one morning (especially when have an early class, then go back and sleep before their next class, and basically repeat their morning routine when they wake up the second time).  On the opposite end, students who take medications for depression or anxiety often forget to take their medications (especially when they are feeling fine), but then deal with aches, pains and brain "fuzziness" the next day that they may not even realize is from skipping a pill. Using these simple day-labeled boxes takes the guesswork out of whether or not you have taken your pills.

Keeping prescription medications- especially ADD meds- in a lock box reduces the temptation for others to "borrow" any pills. Unfortunately, ADD medications are abused as "study aids" and "weight loss pills" on most campuses. Let me note here that it is a FELONY to buy or sell these drugs- even ONE pill to ONE "friend".  WARN YOUR CHILD. If your student takes ADD medications, encourage them to keep these prescriptions in a locked box, tucked away in their room. Once a week, they can fill their daily dispenser, and keep that in a safe but easily accessible place. For girls- there are cute med boxes that look like make up pouches or wallets- and some even have a spot to keep a copy of your insurance card. By the way...if you have a senior in high school, consider putting them in charge of their medications in this same fashion, so next year isn't so challenging!

  

BOTTOM LINE: For students (and the rest of us) who take daily medications, using a simple daily pill dispenser improves accuracy and keeps us healthier!

(Disclaimer- I have no ties, financial or otherwise, with the makers of these products, but they both work great.)

Moving in to a DORM? Double Check Your Vaccinations!

Why do COLLEGE STUDENTS need the Meningitis Vaccine?

What is meningococcal disease? The bacteria Neisseria meningitidis causes a range of illnesses that can rapidly progress to be fatal if not immediately recognized and treated. Meningitis is an infection of the lining of the brain that can cause coma, sepsis and death. Early symptoms start like the flu- fever, headache, body aches, and possibly nausea and vomiting, then the headache progresses in severity, the neck becomes very stiff and painful, and the person may become confused or even unconscious. A very specific RASH can alert clinicians to this dangerous disease- it is dark red/purple and does not whiten if pressed upon. This rash is caused by leakage of blood vessels as the bacteria releases toxins into the blood stream. Survivors of a severe meningococcal infection may have lost fingers, toes or even limbs as a direct result of this blood vessel damage.

Meningococcal disease is especially noteworthy here in Texas, where we were the first state to pass legislation to require the meningococcal vaccine for every college student. Sadly, this legislation came after one student at Texas A&M died (Nicolis Williams) in 2011, and a University of Texas sophomore (Jamie Schanbaum) had lost both legs, fingers, and narrowly survived meningococcal infection. The Texas law is named for both of these students. Jamie has remarkably gone on to not only champion efforts to educate about vaccine prevention for meningococcal disease, but to win a gold medal in the paralympics.

Who needs this vaccine?  The meningococcal vaccine has NEW RECOMMENDATIONS- all adolescents should still receive their first shot (the MCV4) at age 11-12, as previously recommended, but now we know they need a BOOSTER DOSE at or after age 16, before they head off to college. Although initially thought to offer protection for a decade, it turns out that the immunity begins to wane in this age group after 5 years. Yes, they still needed that earlier vaccine to protect against the herds of kids joining them in close quarters at school and summer camp, but we want them maximally protected as well when they move into that dorm!

In addition, military recruits (also living in crowded quarters like a dorm) and anyone who has had their spleen removed should get this vaccine.  Travelers to sub-Sahara Africa during the dry season are also at increased risk, so vaccination is recommended for this group as well.

BOTTOM LINE: Protect your adolescent against this rapidly progressive, dangerous disease by making sure they received not only their initial vaccine at 11-12 years, but also their BOOSTER before they head off to college! (If they are already in college but missed their booster, add this to their holiday wish list...)

Image above from NY Times

Top 6 Non-Medication Items in a College First Aid Kit

A College First Aid kit is my favorite personalized gift for graduating high school seniors, and a MUST for every young person heading off to college. As an urgent care physician seeing students at the University of Texas, I have significant insight as to how teens handle their first illness away from home. As you start your child's first aid kit, here are SIX NON-MEDICINE items I suggest:

1. THERMOMETER- Preferably two inexpensive digital thermometers (because  I've found their shelf-life is often less than a school year.) 

• Knowing whether or not you have a true FEVER (temperature >100.4*) is a very helpful piece of information, especially when you are calling in to a nurse hotline.
• Allergies frequently cause a mildly elevated temperature (99*) 
• Viral infections often will cause a SUBnormal temperature of around 98* (especially after the first day), even though you feel "feverish" or chilled. 

2. ALCOHOL WIPES- purchase a small box of individually packaged wipes (~$1). Remind your student that they should USE these wipes on the thermometer BEFORE & AFTER checking temps.

3. BANDAIDS- do NOT go cheap here, splurge for the $4 box that includes flexible fabric finger tip and knuckle strips, because these actually stay on effectively. If your student is studying architecture, buy several boxes (seriously!) They work with exacto knives- enough said. A box of "blister" bandaids is nice for students headed to large campuses- their FitBit step count is about to skyrocket.

4. COMPRESSION ("ACE") WRAP- I prefer the 3" size. Remind your student of the RICE pneumonic:   Rest * Ice* Compression * Elevation for injured extremities. Add in a ziplock bag for a DIY cold pack for bonus points.

5. BULB SYRINGE- If your child is an ear-wax-builder-upper, encourage them to use this tool to periodically flush out their ears (INSTEAD of Q-tips, which typically pack in the wax further).

6. PAPERWORK- stick in an extra copy of your family's health insurance card, along with a medication list (if your child takes prescriptions regularly, prescription or not). Write the date of most recent TETANUS shot on the med list. Yes, you fill these things out on line for the school, but your student may end up at an outside urgent care clinic at night or on a weekend, and it's wonderful to have these physically on hand (or at least on their smart phone as a picture.)

BOTTOM LINE: A college student's first aid kit should start with a thermometer, alcohol wipes, "good" bandaids, an ACE wrap, bulb syringe & copy of your family health insurance card.  

PS. Virtually every university now has a 24 advice line staffed by an actual, live human being- be sure your college student has that number programmed in to their smart phone!

Summer Travel First Aid Kit

Packing up for your summer vacation? If you are driving, may I suggest you prioritize finding a small space (maybe under the passenger seat as above) to stash a first aid kit? If you already keep one in your car (hello, fellow soccer/dance/volleyball moms!) then let this be your reminder to pull that kit out of your car, CHECK EXPIRATION DATES, and replenish all your used up supplies.

What's in my kit? Although I will confess my kit is over-stocked with "extras", here is my basic essentials Top Ten First Aid Kit List:

1. Ibuprofen (trade name Advil/Motrin)- for headaches, muscle aches, fevers or menstrual cramps.
2. Acetaminophen (trade name Tylenol- to supplement the ibuprofen if the ache or fever is severe.
3. Antacid tablets (TUMS or Rolaids)- still the fastest relief from heartburn/stomach acid.
4. Hydrocortisone cream (Cortaid)- for anything that itches (bug bites, allergic skin reactions.)
5. Triple antibiotic cream- for cuts/scrapes (after washing copiously with water.)
6. Bandaids- the GOOD kind that really stick, with specifics for knuckles, knees, and most commonly, HEELS (for those blisters!)
7. Benadryl tablets- for an intense allergic reaction to food, stings, etc; also may be used to help nausea or insomnia.
8. ACE wrap- handy to limit swelling of a sprained ankle, knee or wrist.
9. Aspirin- one daily helps prevents blood clots from prolonged sitting while traveling; also I like to  keep this in case an adult has symptoms of a possible heart attack.
10. Imodium- I do NOT recommend this to stop infectious diarrhea (so do not take if you have a fever), but if you get a "nervous stomach" with the thought of flying, driving, or simply being cooped up in a car with your relatives, consider this medication to calm down your bowels.

Bonus: THERMOMETER! Not a medication, but definitely should go in there

BOTTOM LINE: These few basic first aid supplies should get you through 99% of the medical urgencies that crop up on your trips. Remember the creams may count as "liquids" so slip them into your airline-specified ziplock baggie if you are flying!

Doctor's Help for Fear of Flying

If your fear of flying is putting a damper on your summer travel plans, know that you are not alone- and that your family physician can offer you a few different medications that may reduce your stress. Many patients have told me they were afraid to ask for any medication, because they did not realize these drugs could be used situationally for a single event such as a flight.

Beta-blockers- this class of medication simply keeps your heart from racing, and lowers your blood pressure. This drug is used for public speaking anxiety as well.

Sedatives- although when used frequently these medications are definitely addictive, using a short-acting sedative for a flight is a very reasonable option. Alprazolam (trade name xanax) is commonly prescribed in small doses (and very small quantities). Note that these pills should never be combined with alcohol. 

Sleep aids-these are longer acting sedatives indicated for treatment of insomnia; physicians consider prescribing these for flights longer than 6 hours, such as fully across the country or overseas.

Behavioral modifications are also key to help the time "fly" by; consider:

• Noise-cancelling headphones make a world of difference, especially if you can use them to engross yourself in a visual media as well, such as your favorite television series or movie. 
• Music by itself, particularly a very familiar whole album or musical 
• Crazily addictive games on your phone or iPad 
• Puzzles or word searches

Avoid stimulants like caffeine and decongestants- no need to ramp up your heart rate before you even get on the plane!

If you have the luxury of time before you travel, consider biofeedback, hypnosis, or meditation training.

Bottom Line: Fear of flying is common- plan ahead and talk to your doctor if you would like to consider a medication to lesson your stress.

ABCs of HIV for National Youth HIV & AIDS Awareness Day

Today, April 10, 2016, is National Youth HIV & AIDS Awareness Day. Why do we need a YOUTH awareness day? Because in 2014, nearly 10,000 young adults were newly diagnosed with HIV (age 13-24 years, 9731 cases). And that is only young people who got TESTED and therefore were DIAGNOSED. Nearly half of young people already living with HIV are UNAWARE that they are infected. In honor of this HIV Awareness Day, here are my quick HIV ABCs:

• A: ALL people ages 15-64 should be tested for HIV at least once, regardless of risk factors. Why?Widespread testing will help identify the estimated 1 in 8 people living with HIV infection who do not know their are infected, and now with our highly accurate rapid testing, false positives are extremely rare.
• B: BISEXUAL- meaning remember that HIV occurs in BOTH genders, as well as emphasizing the fact that HIV is most prevalent in gay, bisexual and other males who have sex with men (but not all MSM identify as gay or bisexual.) Nearly 20% of the 44,000 new HIV diagnoses in the US during 2014 were female, and the vast majority (87%) were infected through heterosexual sex. 
• C: CONDOMS- "Safe Sex" means using condoms consistently and correctly, for all forms of penetrative intimacy. To be specific, use condoms for oral, anal and vaginal sex. (While oral sex is low risk for HIV transmission, other STIs such as gonorrhea and herpes simplex are easily transmitted this way.) Condoms do not make you bullet-proof, but they work extremely well -up to 98% decrease in transmission of HIV.

BOTTOM LINE: HIV has not disappeared, and many who are infected do not know. GET TESTED!

STD Awareness Month 2016 "Talk. Test. Treat"

"TALK. TEST. TREAT."

Perfect theme for the CDC's 2016 STD Awareness Month! We can't have AWARENESS if no one is talking about these diseases. And because these diseases are mostly SILENT, you can't have AWARENESS that you have an STD unless you TEST for it.

The Bad News: 

• Sexually transmitted infections affect over 20 MILLION Americans every year, and young people ages 15-24 make up over HALF of these cases. 
• Chlamydia, gonorrhea and syphilis are on the rise for the first time in a decade.
• Gonorrhea is more difficult to treat because it has become very resistant to antibiotics
• Curable bacterial STDs, if not diagnosed and treated in a timely fashion, can have lasting impact by causing chronic pelvic pain or even infertility. 
• Young people are the least likely to get tested and treated for numerous reasons, including ignorance that their non-intercourse sexual activities can transmit STDs, fear and embarrassment of telling their parents, inability to pay for or access healthcare on their own.

The GOOD News:

• Many of these infections are preventable, and testing is easier than ever (no pelvic exam required in most cases- only a urine test for gonorrhea and chlamydia, and a blood test for HIV and syphilis). 
• Gardasil vaccine prevents the vast majority of genital warts and HPV-related cancers.
• Hepatitis B vaccine prevents Hep-B related cirrhosis and liver cancer.
• Proper and consistent condom use greatly reduces transmission of most STDs.

I have found that sharing stories (with accurate medical information) is a powerful tool for teaching about sexually transmitted infections. Check out the newly released second edition of Seductive Delusions: how everyday people catch STIs.

BOTTOM LINE: TALK.TEST.TREAT  and learn how you can help spread KNOWLEDGE and stop the spread of DISEASE.

Pre-Gaming with ADD Meds...A Dangerous Party Plan

Binge drinking in college students is not exactly breaking news.  My patients repeatedly explain "if you can't handle five shots of vodka, you are pretty lame".  They toss back multiple shots, have beers, then top off with mixed drinks. Hit the replay button once or twice, and the weekend is over. On Monday morning, they head back to class, seeming none-the-worse for wear beyond a headache.  How is this possible? Especially for adolescents who are only STARTING to drink, how exactly can they tolerate this volume of alcohol?  I started asking...and heard the same answer, over and over. "Well, to be honest, I pre-game with my ADD meds". 

PRE-GAME? Yes. Young people have figured out that when they take a prescription stimulant right before going out to party, they can "hold" more liquor. The stimulant takes away the typical buzzed, relaxed sedation of the first few drinks. Many have told me they "feel absolutely nothing at all from the alcohol...till I reach a certain number of shots, then suddenly I go from sober to super buzzed, and then either puke or pass out."

At first this confused me...wasn't the POINT of their drinking to catch that buzz in order to feel more social or confident? It seems counterintuitive. But if the peer pressure now is not only to drink, but to show you are so comfortable with drinking that it doesn't affect you- then this plan makes total sense. Except that this plan is so very dangerous, which makes it terrifying instead.

Unfortunately, not "feeling" the effects of alcohol does not mean that the alcohol is less potent within your brain, liver, bloodstream or nerves. This practice makes it far too easy to reach ALCOHOL POISONING levels, because you have turned off all your body's warning signs. Short term, you can hit toxic levels of alcohol that make you stop breathing. Or enough to "just" pass out...but then throw up and choke on your vomit. Long term, you are taking the HOV lane to end-stage alcohol complications because although you may only drink on weekends, you are getting huge quantities in at one time. And socially, this practice is normalizing binge drinking, because everyone sees their friends routinely drinking numerous drinks without it seeming to affect them.

A recent Cochrane meta-analysis Social norms information for alcohol misuse in university and college students examined 70 studies, including nearly 45,000 students. The premise was that college students have an inflated misperception of how much their peers are drinking, and therefore educating them about the true social norms may reduce alcohol-related consumption and subsequent problems. Although there were some significant effects, the "substantive meaningful benefits" were not enough to recommend policy changes.

As a side note, many students are taking ADD meds they have borrowed or purchased from a friend, which is not only illegal but magnifies their medical risk.

Yes, binge drinking in college has been around for a very long time, and thankfully the majority give up this habit when they hit the real world- if they survive their risky behavior. Note that a standard screening question for alcohol abuse is "have you had more than 4 drinks in one day during the last year?" 

Wondering how many drinks it would take for YOU to get alcohol poisoning? Check out one of my favorite resources: Aware, Awake, Alive

BOTTOM LINE: Doctors, parents and teens ALL need to know the dangers of "pre-gaming" with ADD meds. 

Drug Abuse from YOUR Medicine Cabinet

Prescription drug abuse is at an all time high- no pun intended. Sadly, studies have found that 1 in 5 high school students say they have taken a prescription drug without a prescription. What are they taking? Pain killers, stimulants, and anxiety medications. Specifically, the most common drugs are OxyContin, Vicodin,  Percocet (narcotic pain pills), Ritalin & Adderall (ADD stimulant drugs), and Xanax (called "bars" because of the shape-an anti-anxiety sedative like valium.)

Many people have a false sense of security using prescription medications to catch a buzz, especially adolescents. The prescription element seems to be a stamp of safety for them (similar to "organic" equals "better"-but I digress). Frankly, it terrifies me to hear of kids swapping any prescription medications, particularly ones as potent as these. Add in that these pills are often combined with alcohol, and you now have a recipe to take your breath away- literally. Both narcotics and alcohol can suppress your drive to breathe, and they are additive when taken together.  Accidental overdose is a frighteningly common cause of death for teenagers, and inappropriately used prescription drugs are a major culprit. When I prescribe codeine cough syrup (which is the most common reason I prescribe narcotics this time of year), I always remind my patients that this "cough" medicine is a narcotic, and NARCOTICS + ALCOHOL = DEATH.

Another common pairing of prescription medications and alcohol is "Pre-gaming" with ADD meds, with the intent of revving up with the stimulant so they can "handle" their liquor better...which is a fast track to alcohol poisoning.

What can parents do about this alarming trend?
Number one, TALK to your teen. Ask (in a non-threatening, conversational tone) if they are aware of anyone borrowing prescription medications from friends. Let them know this is DANGEROUS and ILLEGAL. Please throw in the fact that it is a FELONY to buy or sell prescription drugs, and that charge is a one way ticket the wrong direction. The truth is that there is a ton of "altruistic" sharing of medications in college, and that sharing often becomes buying and selling between friends. Kids want the stimulants to help them pull an all-nighter, and that seems like a good and worthy cause to them (although numerous studies have proven all-nighters don't help grades.) Students also want these drugs to lose weight, or "hold their liquor", or  to use as an escape. Acknowledging these issues up front can lead to a more productive conversation, and talking with your teen at least lets them know you are aware of this risky behavior in general.

Next step? Take a close look at your medication cabinet. Throw away expired drugs, and keep close inventory of any potentially abused medications. If your kid is on ADD meds, make sure they are taking them as prescribed. Finally, if you realize that you are using prescription drugs inappropriately, it's time for a difficult conversation with your physician. You can't abuse it if we don't prescribe it, so this is a problem we need to tackle together, and there are solutions beyond simply cutting you off.

BOTTOM LINE: Prescription drug abuse is out of control. Learn the facts and protect and educate your teens. Get more info at the National Institute on Drug Abuse.

STILL Coughing? Will Anything Help?

Is your cough driving you (and everyone around you) nuts? If your purse, coat or pant pockets are overflowing with empty cough drop wrappers and tissues, than you've dealt with that cough on your own long enough. Whether the original culprit was a common cold, the flu, or "just" seasonal allergies, coughs can take on a life of their own as our lungs gear up mucus production and airway spasm. My rule of thumb is that lingering coughs should be on a clear decrescendo- getting slowly but steadily better each day. If your cough is getting worse by increasing in frequency, intensity (like those fits of coughing hard enough to make you leak urine), or preventing sleep, then it's time to let a doctor listen to your lungs and take a full look at you.

But what can be done for a cough that wont go away? Do I need antibiotics?
The vast majority of persistent coughs do NOT need an antibiotic, because they are typically a left over reaction from a respiratory virus.  However, if you are a week or more into your symptoms and things seem to be improving, but then suddenly you feel a ton worse and develop chills, sweats and fever as your cough worsens, this might be a bacterial infection setting up shop AFTER the virus cleared the way past your body's defenses.- possibly even pneumonia. For this scenario, yes, you often do need an antibiotic. More commonly, though, frustrating coughs are the result of developing  some over-reactive airways and therefore, you may benefit from inhalers or other asthma-style medications. Not uncommonly we prescribe a very brief course of oral steroids (prednisone) for someone who develops wheezing and airway spasm after a viral respiratory infections.

But I don't HAVE asthma- so why am I coughing? People who did not grow up with the diagnosis of asthma can still have an asthma response to a respiratory tract infection or seasonal allergies- we call this "reactive airways disease". Your lungs make extra mucus and have more inflammation,  together causes airway spasm- audible to the examiner and sometimes to the patient themselves as a "wheeze". The asthma inhalers or breathing treatments through a nebulizer (machines that deliver the asthma medication as a fine mist that is inhaled through a mask or mouthpiece) work to pop open those airways, stopping the wheeze that was caused from the airway spasming shut in areas. That relief is temporary, however, because it fixes the problem and not the cause. The steroids are the real "fix" because they decrease the inflammatory response that started the whole cycle.

What else might my doctor give me?
There are a variety of cough suppressant combinations that include dextromethorphan, which is in most over the counter cough and cold products. Some persistent coughs without the reactive airway component will respond to a prescription cough suppressant called benzoate (brand name tessalon perles.) Additionally, a prescription narcotic cough syrup may help you sleep at night and reduce the nighttime exacerbations. Finally, your doctor can remind you of some traditional home remedies such as cool mist humidifiers and topical menthol products that may help your symptoms. Finally, sometimes a cough comes from other sources, such as acid reflux or sinus drainage, which require different treatments.

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

Flu Vaccine- NOT TOO LATE!

* The "C" in the flu tests pictured above is for "control"

Friends, family, colleagues and everyone else- FLU SEASON was mild to begin with, but now we are really gearing up. Pictured above are two positive flu tests from one morning this week (two of many). The extra good news is that so far I have not seen anyone with the flu who was vaccinated, though certainly that can happen. Remember that seasonal influenza causes thousands of hospitalizations and deaths every year in the United States, and the flu vaccine is our best method to prevent or at least reduce the severity of the flu.

This year, we hit a home run on the strains in the vaccine, as we have a very good match between the vaccine and the current strains. Yesterday's CDC press release notes that the overall effectiveness of this years vaccine is 60%. While that number might not sound super impressive, reducing the total healthcare burden of people needing to seek care for flu symptoms by 60% is huge in our total population! Also, keep in mind that if you receive the vaccine but in your case it is not fully effective so you still get the flu, your symptoms should be less severe, and your infection is likely to resolve more quickly. I'm posting this today, though, not for adamant anti-flu vaccine holdouts, but for the well-intentioned stragglers that simply never got around to getting the vaccine. Please, it's not too late- GO GET VACCINATED!

CDC data shows happily that only two states- Arizona and Oklahoma- are having HIGH levels of flu-like illnesses right now. Texas, along with Arkansas, Connecticut, Florida, Hawaii, Illinois, Maryland, Nevada, New Jersey and New Mexico are close behind with "moderate" levels, which is no surprise with what I am seeing in my patients.

Remember- not all flu looks the same. Fevers can be high or minimal. Headaches, sore throats, muscle aches, cough, runny nose and fatigue are common. Stomach symptoms with nausea, vomiting or diarrhea can occur independently or with the other symptoms.

When should you go to the doctor? If you are MISERABLE- feeling like a truck hit you, rather than a common cold or allergies causing upper respiratory symptoms, then go sooner rather than later, because if you do have the flu, the anti-flu medications are maximally effective when started within 2 days of symptoms beginning.

Does everyone need medication if they have the flu? No. Most otherwise healthy young people can manage without anti-viral medications, but they may certainly benefit from a cough suppressant or decongestant.

Why bother testing for flu? There are several reasons, partly for you, the patient, and partly for public health/your family. If a college student living in close quarters in a dorm has the flu, for example, we would rather they not infect their roommate and classmates. Knowing they have the flu helps us advise them on when to return to class, or perhaps help parents who live nearby to decide to whisk them home for a few days of chicken soup and true rest. Remember, if a flu test is POSITIVE- you've got the flu. If it is NEGATIVE...you still might have the flu. (For more explanation, see Was My Rapid Flu Test Accurate?)

BOTTOM LINE: Flu season is still here and it is NOT too late to get vaccinated!

Got RED? WEAR IT FRIDAY, 2/5/16

Don't wait for Valentine's Day next week to wear RED- pull it out tonight to wear on Friday, February 5, 2016. The American Heart Association has set aside the first Friday in February to call attention to cardiovascular disease in WOMEN. Did you know that one in three deaths in women are caused by heart attacks and strokes? This is not to minimize the deaths and struggles from cancers, but to create awareness about the incredibly high frequency of these diseases in women, and therefore encourage more women to take positive steps to improve their health. The best news is that the  vast majority heart attacks and strokes can be PREVENTED when people recognize, modify and treat their risk factors. So...let's start with basics:

What is a "heart attack"? The heart is ultimately just a muscle, and like every other muscle, it needs a unique blood supply to provide the nourishment it needs to work. Although the heart muscle's  job is to move blood by pumping it, that blood being moved to the body is not the same blood that feeds the heart muscle itself. Instead, there are smaller blood vessels (called coronary arteries) that carry the specific blood that supplies the heart muscle. If one of these small arteries gets a clot or blockage that obstructs the blood flow, then the area of heart muscle that requires that blood supply will have the "attack" because it is not getting the fuel it needs, so that portion of the muscle can be hurt or destroyed. If the fuel line in your car were clogged, then your engine would have an "attack" because it wasn't getting fuel. Similarly, a stroke is when an area of the brain has it's blood supply cut off by a clot. 

What can you do to decrease your risk of a heart attack or stroke?

1. Quit smoking (always number one on my wish list for patients to improve their health!)

2. Know your numbers- what is your BLOOD PRESSURE? your CHOLESTEROL? your BMI?

3. Move MORE- whatever your baseline activity is, kick it up a notch!

Rather than focusing on losing twenty pounds,  running a marathon, or getting off all your blood pressure medications in one month, pick a few small changes that you can easily incorporate into your life as a permanent change.  

1. Consider starting these changes by scheduling a physical with your family doctor to learn your "numbers" to help prioritize your lifestyle changes.

2. Commit to one vegetarian meal per week (if that is not already part of your standard food rotation). If you are vegetarian, look at what you eat and add in new fruits or vegetables in different colors than you typically consume.

3. If you are inactive, start walking 10-15 minutes per day. If you walk a mile per day, kick it up to a mile and a half. If you walk or jog a couple miles per day already, alternate with an exercise bike or swimming. The point here is that WHATEVER you are doing, take it up ONE notch.

BOTTOM LINE: Wear RED this Friday, 2/5/16, serving as a reminder to you and the people you love to prioritize learning your own personal risk for heart attacks and strokes- then start making changes to prevent these diseases!