Coping with Grief and Death

It has been a while since I have written in this blog due to long hours of work and things that tend to get in the way of medical blogging. I have to admit that I have never really written a serious post before... or at least not that I can remember. Writing scientific journal articles, somber patient information columns, or being an associate author on professional medical books are commonplace for me, but I rarely write serious blog posts.

 Today, I am writing one. Granted, a smidgen of my dry medical humor may find its way in here: I can't help myself, I'm wired that way. (Image taken from http://www.google.com/imgres?imgurl=http://olive-drab.com/gallery/photos/soldier_grief_korea_sm.jpg&imgrefurl=http://olive-drab.com/gallery/description_0113.php&usg=__P9CWq9sxgmUXri7Dsdg9wxXnBMg=&h=288&w=360&sz=28&hl=en&start=34&sig2=SoxMB-VnwSHO_RYIY1XiNQ&zoom=1&tbnid=O2p9ttk41z9J2M:&tbnh=97&tbnw=121&ei=NkBTUZOmAsHXygHB04CICw&prev=/search%3Fq%3Dgrief%26start%3D20%26um%3D1%26hl%3Den%26client%3Dfirefox-a%26sa%3DN%26rls%3Dorg.mozilla:en-US:official%26tbm%3Disch&um=1&itbs=1&sa=X&ved=0CEYQrQMwDTgU)

Over the years, I have spoken with several patient families and patients about their imminent death from their terminal illnesses.  In fact, I have given the Death Talk more times than I can count. The "death talk" in doctor speak is that horrible moment when you have to pass on the information to the patient or the patient's family or both that there is noting more that medicine can do. I hate doing that. I really hate it. But apparently, I'm good at it, because a lot of my colleagues over the years have had me do it, even when I was a medical student. One, this is not something that you want to be good at. No one does. So you'll never see a medical student grin and say with enthusiasm, "I want to be the best 'death talk' doctor ever!"

No one wants to tell someone that they are dying. No one wants to tell a parent that their child is dying. No one wants to tell a family that their beloved grandfather has inoperable stage four cancer and there is nothing more you can do.

Yet, it is drastically important, and even more important that it is handled with empathetic hands. I remember when I was interviewing for medical school, that I was asked the question, "What would you do if you had to tell a family their loved one was dying? How would you handle it?"

I had the unfortunate circumstance of being able to tell them that I had already had to do that. My family is quite familiar with death and dying, especially of the young. So I have had much experience prior to entering medical school.

Recently, I stood at the hospital bedside of a relatively young, elderly man whom reminded me of Jolly Old St. Nick. "Has anyone of the attending physicians or other staff told you about your condition?"

(To protect the identities and feelings of the patients I mention here in this blog, I will only paraphrase their words.)

The patient indicated that no one had told him anything and that  he had been there in the hospital for two days. That morning was the first time that I met him and I was sent by the main attending to speak with him for the first time. I was the one asked to tell him that he was going to die.

As I explained to him about the results of the scans, how immensely the cancer had spread, and how there was nothing more that we could do for him except arrange for hospice to make him as comfortable as possible, he just watched me with moist eyes. Finally, I asked, "How long have you known?"

He answered that he had the feeling for the last two weeks. He had already been settled to the idea of his impending death before even stepping into the hospital. He had felt healthy for the most part except that he had begun to have a tiny bit of problems swallowing food. (A metastasis tumor had invaded his esophagus.) He had no logical reason at that time to feel that he was dying, except for a warning from his maker.

There are many times that death comes at us unexpected, but many times people are strangely prepared with the knowledge that they are going to die. This is one of those tender mercies that are given to us from the Lord that help us cope with what's coming ahead.

Perhaps, I will get tonked by some doomsday preppers that refuse to believe in God or Christ or any supernatural creator, but being in the medical field, seeing the things you see everyday, you know there is a God.

Besides, we have to have a God, because we've got to have someone to blame, right? It's easy to blame God that our loved one has died or that we have an incurable sickness, isn't it? Why didn't He save my father, my brother, my sister, my son, my daughter, my wife, my mother, my friend? And we get angry with God.

We get angry with the doctors. We get angry with each other. Angry with the patient for doing something real or imagined to bring the illness upon themselves. Angry at the system for not providing better care. Angry at the government or the president for not strengthening levies enough to prevent a hurricane from destroying our city or for not warning us fast enough against an earthquake. Or just plain angry at the world.

What about the times we become terribly depressed about losing our loved ones or being told we are terminal and have limited days left? Or we feel entirely emotionally numb and guilt trip ourselves into thinking something is wrong with us, because we don't feel anything. Do we care at all, if we don't feel upset or sad? Are we terrible people because our emotions have shut down?

In the days to come, there will be many disasters ahead of us, whether they are on a personal level or a national level. Whether they are financial or medical, or whether they are a natural disaster or man-made due to some crazy person going on a killing spree. And through out these disasters, we're going to through a series of emotional and mental rollercoasters on top of everything else that we may face. These psychological rollercoasters are better known as the stages of grief.

Another patient of mine complained about being constantly angry. She was a darling elderly lady whom had an adult form of leukemia, which is a cancer of the bone marrow resulting in abnormal production of blood cells. She indicated that she didn't understand why she was so angry at everyone. She was normally a happy and kind person, but now she just wanted to punch someone in the face for anything. With tears in her eyes, she asked me what was wrong with her.

First with a smile, I told her that there were definitely some people that deserved being punched in the face and that if she really wanted to do it, she had my permission. An old lady smackdown was better than pay-per-view.

(Yeah, I know, I shouldn't encourage a frail, elderly patient to pummel people. I'll smack my own wrist. Bad Dr. Princeton, bad.)

But after she stopped laughing, I asked her if anyone had ever explained to her about the stages of grief. When she told me that no one explained to her anything about her situation, I made a mental note to punch a few people in the face myself. Okay, so I never followed up on that, but it was a good thought, considering the fact that she wasn't one of the first patients that no one had explained anything to.

Then I showed her this little video, outlining the stages of grief; showed to to her and her entire family. Yes, a cartoon with a giraffe, that well when you see it you'll be grateful for censorship.

The stage of anger, as shown by the video as being explosive and undirected, is something that  has been unleashed on me more times than I can count in the hospital setting by patients and family members. Mixed martial artists have nothing on a doctor who has just given the death talk. It can be pure guerilla warfare: the verbal projectiles are a force to be reckoned with.

So the stages of grief are brought down upon your head WWF pile-driver style and what do you do? You do what any rational adult would do, run screaming for a bug out location, because the end of the world is raining down on you.  No, not really. You let them go through the stages of grief, supporting them every step of the way. Because you know that everyone goes through them.

Stages of Grief

Stage 1: Denial

Stage 2: Anger

Stage 3: Bargaining

Stage 4: Depression

Stage 5: Acceptance

The video is a good illustration of these stages, so I will be brief with additional explanations. But I do want to mention that emotional numbness, can occur at any of the stages before the stage of acceptance, but it is most likely to occur around the stage of denial. Some psychologists say that it could be the pre-denial state, others say that it is the post-denial state. I say that it is a sucky state.

Emotional numbness is associated with survivor's guilt in the case of those close to the dying person. Those in this stage are tempted to run away from the dying person or the traumatic event. They tend to label themselves as cowards and they refuse to want to talk about the thing that causes them grief.

When we are dying we may find some of our friends seemingly "abandoning" us. They'll quit calling or coming around. They'll avoid us in places where we would otherwise meet.  In fact, they just can't take it. They become emotionally numb and fall prey to the tempting grip of chronic denial. This is very common and a part of the natural process.

Then there are those of us, whom are emotionally numb about the death of a loved one because we love them so much that our minds just can't handle the stress of it all and we temporally shut our emotions down, so that we can appear to be strong for everyone, including the person dying. This also is a common occurrence.

Or we could be facing a mass casualty event or something of disastrous proportions where we go numb in order to process the information quickly and effectively and do our jobs. After it is over we may or may not collapse into a fit or tears or exhaustion. And all of these responses are normal.

At a particular hospital, a man was brought into the trauma bay, looking like a pile of hamburger attached to a head and torso. Motor vehicle accident: diesel verses paraplegic pedestrian in a wheelchair.  We did all we could to save him, but he didn't make it. Blood was everywhere, all over the trauma bay floor, the bed, the equipment, and us.

We were all emotionally numb. Seriously, you know when a person is emotionally labile, because their face goes slack and they just stare. We all were zombies. The zombie apocalypse had struck the trauma bay and didn't go away until the attending trauma surgeons engorged themselves on beef stroganoff in furious bouts of emotional eating and the rest of us broke down in stairwells or supplies closets crying.

The stage of anger can produce unwarranted bouts of frustration lashed out at anyone that comes near. This stage can manifest in a form of deep-seated bitterness or outward displays of rage. It can be externally manifest or internally held. When we are in this stage, we find ourselves participating the blame game and saying things that we would never otherwise say to those we love.

Bargaining comes next. Here is the stage where those that aren't religious suddenly start carrying roseries or praying. Where we argue with doctors, offering money or whatever it takes, if they would just continue to try something else even when all available resources and solutions have been exhausted. We bargain with ourselves: we would give up X, if we could receive Y. We would give up our lives instead of our child. "God take me instead of he/she."

Then follows is depression. There is nothing we can do, there is no hope, no recourse, no control... just fear and loss. This stage is horrible. At least with the anger stage we can take it out on something else. At least with the bargaining stage we are doing something or trying something. In this stage, we feel as though we and the world and God have given up on us. These feelings which maybe real to us are not true. This stage is one of the hardest to get over. Because the loss is so evident, even if our loved one is still alive or we have X amount of months still left.

Before I get to the last stage, I do need to mention the fact that we can easily be trapped in any stage for years. A man whom lost his son to poor medical care has been angry for twenty years at God and the hospital. He still is angry. Others can be depressed for years, changing depression from grief to major depressive disorder.

Lastly, after all these emotional trials are over, we should eventually reach the stage of acceptance. This is the stage where true change takes place. This is the stage where the terminally ill take care of all of the things that they wanted to do in their lives. This is where we let go of the emotional pain and suffering, and focus on getting our things in order, making amends, and making arrangements for our survivors to be taken care of, so that there are no regrets. This is the stage where we hold the hand of our dying grandparent, parent, spouse, friend, or child and know that they will physically suffer no longer. We may not have them physically with us, but they will always be around us spiritually, in memories, and/or in our hearts.

The stage of acceptance is the fulfillment of all our emotional trials and fills us with a feeling of peace that doesn't remove mourning but makes sense of it. This is the stage that will save us in the future and give us the strength to move on.

A colleague once said to me, "The number one terminal illness is life; we all die eventually. There is nothing wrong with death, it's just how we cope and deal with it."

Next post, I will continue this discussion in terms of coping with mass casualties and critical incident stress debriefing. May you and your loved ones be blessed in your times of need and be comforted in any sorrows that you may face.

Summer's Here and So is Swimmer's Ear

To all those that are practically part fish out there: Yeah, you know who you are. The ones that can't stay away from water. The smell of chlorine gets your blood pumping and you all but grow fins. The water calls to you, beckons sweet nothings. And there you are, jumping in, yelling "Cannonball!" But a few days later, you come into my office complaining of ear pain.

Well, stop it. Stop that water addiction. Your poor ears are ten seconds away from sitting you down for an intervention. But we all know your intense Romeo & Juliet relationship with water, so your ears will just have to suffer. Right? Well, not completely.
So, let's talk about Swimmer's ear: what it is, how to identify it, how to prevent it, and how to treat it.

Often even in medical settings, swimmer's ear, or in expensive medical terms, otitis externa is often mistaken for otitis media, which is an infection behind the tympanic membrane (ear drum) and it is mistakenly treated with oral antibiotics that don't do jack for it. Yep, antibiotics taken by mouth don't do diddly squat to treat it.

Distinguishing Swimmer's Ear from Otitis Media
This is where understanding the difference between the two main types of ear infections comes in handy.

Otitis externa is an infection that usually presents with a swelling of the external auditory canal which is fancy and again expensive way of stating outside ear canal. Also, it will typically have white, icky gooey gross stuff drain out of it, in a condition called otorrhea, medical jargon for runny ear.
Another characteristic is that the external auditory canal will often times swell shut, thereby causing a temporary hearing loss.

Fevers may be present but rarely go above 101 degrees Farenheit (38.3 degrees Celsius).

Other characteristics: Most common in the summer. Recent swimming. Pain is achieved by pulling on the ear.

Otitis media is an infection with fluid and pus behind the ear drum. The condition occurs most commonly in winter months and is associated with a recent upper respiratory infection. Has a runny nose then think more otitis media. Children with it will often act  more restless at night.

As far as drainage, the pus typically doesn't drain out the ear unless there is a perforation of the tympanic membrane. This occurs when the pressure behind the eardrum becomes so great that the membrane blows open like a pair of briefs after a burrito binge-fest, thus letting the pus go pouring out screaming "free at last!"

But under normal circumstances, there is no drainage from the ear, unlike in otitis externa which runs a marathon.

Fevers are present the majority of the time and are often times greater than 101 degrees F (or greater than 38.3 degrees C)

In addition to fevers, sufferers of otitis media most commonly have a dense loss of hearing that feels similar to trying to hear while under water.

Hearing loss can be up to 30 decibels is more commonly seen in otitis media than in Swimmer's ear... because normally, otitis media doesn't drain, which is why one of the main treatments for chronic otitis media is to place tubes in the ear drums. (Note: otitis externa can cause hearing loss if the canal is occluded due to increased swelling.)

Speaking of drainage from the ear, the type of otorrhea can actually help you in diagnosing what type of ear infection or injury you have.  Yeah, I know what you are thinking: "Ewe, I don't want to know more about diarrhea from the ear!" But come on, you know you're curious. It's like the trainwreck that you just can't help staring at. It has that so gross but so addicting thing about it. Pretty soon, you're going to start looking in people's ears, searching for waxy treasure and loving every minute of it.

So here it goes: The low down and dirty of ear drainage.

Otitis Externa

• Acute Bacterial  --- Scant white mucus (yummy) but can be thick and juicy 
• Chronic Bacterial --- Bloody drainage
• Fungal --- Fluffy and white like a kitten. But can be black, or bluish-green. Ahh, it's colorful.

Otitis Media with Perforated TM

• Acute --- Yellow to white pus with Pain
• Chronic --- More Pus but without Pain

Head Trauma

• Cerebral Spinal Fluid Leak --- Clear, watery 
• Bony Trauma --- Bloody mucus

Had to throw the trauma stuff in there, because heck this is a wilderness/disaster medicine blog. Got to keep it real. ;)

So before I get too technical, I might as well show you the anatomy of the ear. I'm only doing this for you. I, personally, really didn't like anatomy. I smelt like formaldehyde after each class. Parfume a' la cadaver bodies. Not good for the social life, so I'm a little bitter. But for you, I'll make an anatomy exception.

There. That's my extent of giving you anatomy. Feel the love. Okay now, moving on.

Causes

• Swimming
• High humidity
• Higher outside temperatures (a.k.a summer)
• Sweating
• Water contaminated with bacteria (okay, all water is "contaminated" with bacteria unless it comes to you in a sealed bottle stamped "Sterile.")
• Sticking stuff in your ears like Q-tips, keys, toys, unlucky rabbit's feet, etc.

Presentation
Otitis externa presents like you've been kicked in the ear. The American Academy of Family Physicians states that the most common symptom is ear discomfort. But come on. How many of you mer-people will actually jump out of the water long enough to go to the doctor's office for "ear discomfort."

Yeah, that's right. I see you in my office when you're screaming and crying, wailing and gnashing of teeth, because it hurts like a freaking sea horse kicked you in the ear... correction an itcy seahorse. Did I forget to mention the intense itching? Or pruritis, if you want to be technical. Itching = $5 word. Pruritis = $5,000 word. Doctors like to use the $5,000 word: it pays for our yachts, or in my case, my beaten up RV.

So, in a nutshell: Ear discomfort (otalgia, another $5,000 word), which worsens with touching the ear or chewing, and ear drainage (otorrhea. Again, Cha-ching!). A bad case of swimmers ear can be so intense with pain though that the a patient may require analgesics. Patients may also complain of ear "fullness" and/or hearing loss due to the swelling of ear canal until it occludes the opening.

Prevention
Stay out of the water. Okay, that's not going to work. That's about as useless as saying to a room full of drug addicts: don't take this crack that I'm leaving here on the table in front of you, because it's bad for you.

Dry Your Ears
Next option, is to dry your ears after water immersion. Using a blowdryer to gently dry your ears is actually quite affective in preventing Swimmer's ear. The excess moisture in your ear, removes the natural protection of your ear's waxy secretions and thus increases the pH in the canal. This provides the optimal environment for growing bacteria and thus leads to infection. The most common bacteria that infect the outer ear canal are Pseudomonas aeruginosa and Staphylococcus aureus.

Acidify the Canal
Yep, you heard me right. The natural environment of the external auditory canal is relatively acidic around a pH of 4.5 compared to the body's internal pH which is 7.4. This acidic environment protects the canal under normal circumstances from infection with bacteria.  (For more information: Read the article "Change of External Canal pH in Acute Otitis Externa published by the Annals of Otology, Rhinology and Laryngology http://www.ncbi.nlm.nih.gov/pubmed/19999361)

• Mix one part alcohol (rubbing alcohol, not beer) with one part white vinegar.

The vinegar is acetic acid and provides the acidic part of the solution, while the alcohol helps to disinfect and dry out the ear canal. Apply 3 drops of this mixture to each ear after swimming to reduce the occurrence of infection.In fact, this little home remedy is similar to the expensive pharmaceutical treatments requiring prescriptions.

Put Nothing in Your Ears
My boss, Dr. Tacket is quoted to say, "Put nothing but your elbow in your ear."
 So literally, it means put nothing in there. No Q-tips, no keys, no bobby pins, no fingers, no toys, no bugs, no nada. Nothing. Zippo. One, you can damage the external auditory canal, making it much more susceptible to infection. Two, you push the ear wax down towards the tympanic membrane where it can get lodged and cause cerumen impaction, which results in a reduction of hearing.  And three, I seriously don't want to dig out that junk out of your ears. It exhausts me. Granted, digging cockroaches and beetles out of people's ears exhausts me more, because I have to fight my gagging reflex the whole time and end up paranoid for weeks about a bug climbing into my own ear. Not fun, I tell you. Not fun.

Keep Ears Dry
Then don't allow water in your ears. Where good fitting ear plugs while bathing or in the water. A cheap way of preventing water getting in your ears while showering is to put a cotton ball in your ear with vaseline on it (on the side of it facing outward). This acts as a water barrier. Then immediately remove the cotton balls or ear plugs from your ears once you are out of the water.

I know, I know. I just said don't put anything in your ears. Well, ears plugs and temporary cottonballs dipped in Vaseline don't count.

Treatment
This is the interesting part. As with all things, the treatment varies according to severity of condition. But there are some straightforward ground rules:

• Oral antibiotics don't work for swimmer's ear at all, period. They only work if otitis media is involved due to perforation. But that's otitis media.
• The antibiotics that are useful are in ear drops or even eye drops.
• The antibiotics must come in direct contact with the bacteria on the surface of the ear canal for them to work.
• If the ear canal is swelled shut, you have to force a wick into it, which is a painful process, and then drop the ear drops onto the wick.
• You need certain instruments available that you can clean the infection debris out of the ear with.
• Six, never, never, never under any circumstances flush the ear with water or get water into the ear. Makes the situation worse like throwing gasoline onto an oil fire.
• Seven, oral antibiotics don't treat otitis externa.

So let's discuss the treatment options and what you can do at home to help treat your loved one's otitis externa.

The main treatment of otitis externa is topical. If the external auditory canal is not occluded, place antibiotic drops in the ear canal itself.

Some of the topical solutions out there, according to the American Academy of Family Physicians include the following (The brand name will be in paretheticals):

Pharmaceutical Acetic solutions (or you can use the homemade alcohol/vinegar solution)

• 2% acetic acid solution (VoSol)                                                       $49
• 2% acetic acid with hydrocortisone (VoSol HC otitic)                    $59
• 2% acetic acid with aluminum acetate (Otic Domoboro)                $18

Neomycin Otic Solutions & Suspensions

• Neomycin with polymyxin B-ydrocortisone (Cotisporin)               $42

Quinolone products

• Ofloxacin 0.3% solution (Floxin Otic)                                             $34
• Ciprofloxacin 0.3% with hydrocortisone suspension (Cipro HC Otitic)     $59

Opthalmic Quinolones (eye drops used for swimmer's ear)

• Ofloxacin 0.3% (Ocuflox)                                                              $29
• Ciprofloxacin 0.3% (Ciloxan)                                                        $30

Aminoglycosides

• Gentamicin 0.3%
• Tobramycin 0.3%

Give 3 antibiotic drops to each infected ear 4 times a day (except quinolones that are only given twice a day) for 5 to 7 days. Warm the bottle of ear drops in your palms before putting the drops in the patient's ear. It minimizes the occurrence of dizziness. (Cold drops of any liquid in the ear will cause vertigo.)

Push the tragus (that small flappy thing that everyone asks why is that thing there in front of your ear canal) in a few times after administering the drops in order to further distribute the antibiotics within the ear canal.

The symptoms should start to cease after 3 days. If the symptoms don't stop than the external auditory canal is most likely swollen shut and the antibiotics aren't reaching the infected skin.

Insert wick using an otoscope (or you can use a headlight strapped to your forehead and a magnifying glass) into the infected ear canal. It will hurt the patient terribly, so be prepared to be beaten. Give the patient pain killer before proceeding.

Ear wicks are made by several different companies, namely Otocell and Americell brands. After inserting the wick, then apply the ear drops to it.

If a wick is required than the drops should be applied every 3 to 4 hours while patient is awake. After a few days (2 to 5 days), pull the wick out and reexamine the ear canal. Redo this process every 2 to 5 days until the swelling of the canal is resolved and the wick is no longer needed.

If there is an ear drum perforation, the only drops that you can use are ofloxacin (Floxin Otic) drops.

For more information, please refer to:
J. David Osguthorpe, MD and David R. Nielsen, MD. (2006). "Otitis Externa: Review and Clinical Update," American Family Physician, 74, pp. 1510-1516.

Robert Sander, MD. (2001). "Otitis Externa: A Practical Guide to Treatment and Prevention," American Family Physician, 65, pp. 927-936.

Anyway, thanks for reading. TTFN

Dr. Princeton, D.O.

Edit Note:
In terms of barotrauma of the ear, or trauma due to changes in pressure:

The pain associated starts during a descent of a plane or while scuba diving. Blood may or may not appear behind the tympanic membrane. If there is blood, then this is called either a tympanic membrane hemorrhage or a serous/hemorrhagic middle ear fluid expression. About 10 percent of adults can get barotrauma after a regular flight, making this a very common occurance.

Trailer Tracks and Sun Strokes: Managing Heat Illness

Okay, it's official: I am a trailer park doctor. Yep, you heard me right. I'm a trailer park doctor. (I just had to put  this picture because I'd like to think someday I could look like that.)

I moved to Michigan this June and have been searching diligently for a house since. A billion bids on 12 homes later, I am still living in an RV. Don't ask. Real estate fiascos are just too painful to talk about. But anyway, let's see how I fair on the trailer park doctor check:

• Living in an RV. Check.
• Changing sewage pipes every freaking five seconds, while bonding with your neighbor about how things back up so easily. Check.  
• Have become the official RV park doctor for the "hey doc what's this big hairy thing on my elbow? I think it moved there yesterday. Is it cancerous?" Check.
• Driving a car with a beatup rear light due to being too stubborn to buy a new one or get it fixed. Check.
• Sporting a paste of meat tenderizer on your hand where a bee stung you. Check.
• Meat tenderizer worked within a minute, but I was too lazy to take it off for five minutes. Double check.

Don't get me wrong: I don't really mind being able to identify with every Jeff Foxworthy Redneck joke-- in fact, I'd like to think I could look like that bombshell picture and I adore RV campers, they're great people--but I have to admit being a trailer park doctor isn't that glamorous. Yet, I am grateful and happy that I am a family practitioner starting out somewhere.

In fact, it sometimes can be hardwork. I have seen too many cases of heat illness this summer among campers that heat illnesses have become my new soap box.

There has been an unprecedented heat wave moving through the northern states, enough that the southern states are laughing at us. Aren't we northerners the pathetic step-children now? It's as though the underworld has opened its gates too let some demon pass a foul air-bisquit upon our once cool countryside. The south is cool. Why can't we be cool too? With this diabolical heat wave we northerners weren't prepared for, comes a lot of heat exhaustion, heat stroke, and dehydration.

 Here I was one glorious Friday afternoon...okay, not so glorious it was a whopping 109 degrees outside, even the flies were fanning themselves.... Contemplating whether or not I should risk the lactose intolerance and glucose rush for a bite of ice cream, and the camp groundsman comes running up to me, saying, "Doctor. Doctor, there's a little boy that's acting funny?"

There are something's that you just don't want to hear when you're about to pound a heaping pile of rainbowbrite icecream down your throat.  I practically choked. "Funny?"

 

"He looks like he's going to pass out." That was even worse.

 

Now it is a true fact that children usually will play until they are about dead. In fact, children don't show signs of hyperthermia or hypothermia until they are severely ill. They literally will play themselves to death. So here was a boy about 12 years old acting like a drunk man after a fraternity kegger. Yep, not a pretty sight on several levels. I knew this was going to be bad.

"Put ice packs in his armpits."

Let's pause here. I know what you are thinking... Ice in his armpits? Yeah, and on his neck and in his groin. Heck, I even had him hug a bag of ice like a teddy bear.

The key to treating hyperthermic illnesses is to immediately do everything you can to bring down the body's core temperature. These treatments are also used post-cardiac arrest to decrease the work load upon the damaged heart muscle.

When a person's body is subject to high temperatures, a series of physiological responses take place starting with vasodilation. Basically, your blood vessels get huge like portbelly sausages, allowing for blood to shunted to your skin in order to cool you down. Your body uses evaporation, which is the most efficient means of cooling down (if the humidity is low).

Here in Michigan, the humidity stays around 50 to 70% and that day was around 109 degrees.

So how do we identify heat illness? Let's break it down into categories of heat illnesses and how to identify and treat each one.

Heat Cramps

One of the earliest heat illnesses is called heat cramps. These occur when a person is hydrated well with plain water, is exercising in the heat, but the body starts to lose essential minerals and salts. These are those people that have just been running around in the heat, drinking lots of water but start having muscle cramps in their legs (especially the calves) or in their sides.

Treatment:

The treatment for mild cases is to drink water with electrolytes in it, such as drinking a quart of water with 1/4 to 1/2 teaspoon of salt in it. Yummy. Or you could add water to a sports drink with a pinch of salt. Severe cases need IV fluid of one-liter boluses of normal saline (0.9% NaCl).

Heat Exhaustion

The precursor to Heat Stroke, which we will talk about later, is known as heat exhaustion. This is the more commonly seen presentation of heat illnesses. This is where the little kids start getting a little whoozy. They start acting "funny," but they will still keep playing.

This condition occurs when the heat stress on the body leads to marked sodium depletion and low intravascular volume. What does that mean for us? Basically, they overheat, get dehydrated, and sweat out all their electrolytes. So when end up with thirsty, sweaty, cranky cooks running around.

The signs and symptoms of heat exhaustion, include the following:

• Thirst (Duh!)
• Fatigue
• Weakness
• Headache
• Drowsiness
• Lightheadedness
• Irritability
• Increased heart rate
• Profuse sweating (but they may stop sweating in the more severe cases)
• Decrease in blood pressure upon standing from sitting or from lying down
• Increased breathing rate
• Nausea
• Hyperthermia is maximum 104 degrees Farenheit or 40 degrees Celcius body temperature
• NO--and I repeat--NO changes in their mental status

                                                                                     Treatment:

Treatment includes giving them as much cold water and electrolytes to drink as possible. The goal should be to get them to drink at least 1 to 2 liters of fluid over 2 to 4 hours.  Except, and this is a big except: the drinks you give them cannot exceed 6% carbohydrate content.  This means no sugary fruit juices and no soda pop. Sorry to all those coke addicts out there. No coke for you!

Remove the patient from direct sunlight and remove all their restrictive clothing, moving them preferrably to an air conditioned environment. (Air conditioners remove moisture/humidity from the air, thus increasing their body's ability to evaporate sweat and cool them down faster.) Try to keep them from shivering by using ambient temperature... shivering increases the body's heat and needs to be avoided.

Under normal circumstances, the best way to rapidly cool a person down is to get them sopping wet and put them into a cool dry room with a fan blowing the AC on them. If you're in a high humidity environment with no AC, then this option doesn't work. Humidity adversely affects the body's ability to use evaporation as a means of cooling down. So if, you're in places like Michigan or an island with a gorgeous beach (which I am envying right now), you're best treatment is to put ice in their pits and groin.

Heat Stroke

This is a medical emergency. No ifs, ands, or buts about it: they need to go to the hospital. This the 911 call that must happen regardless of being in a sweaty campground trailer with a dozen or so people watching you.

To give you an idea of how much of an emergency this is: it is classically defined as a central nervous system (brain) disturbance caused by severe hyperthermia. This is where the child starts acting "really funny" and starts to pass out on you. There core body temperature increases above 104 degrees F (40 degrees C)

The main difference between heat exhaustion and heat stroke is the appearance of altered mental status changes. A heat stroke victim will walk funny (ataxia), talk funny (slurred speech), and pass out which isn't funny. CNS disturbances literally are a hallmark that the patient has progressed from heat exhaustion into heat stroke.

The boy at the campground had slurred speech and passed out twice. You can imagine how concerned I felt while treating him waiting for the ambulance to arrive. He could barely stand with a wobbily gait in a manner called ataxia.

Ataxia, or a lack of muscle coordination most commonly seen in walking, is one of the first neurological signs of heat stroke. The patient with ataxia will walk like a sailor on land... or a person with a severe case of ants in their pants.

Another common sign is that the patient stops sweating (anhidrosis). The lack of sweating can occur in the late stages of heat exhaustion, so it isn't as diagnostic as ataxia.

The signs and symptoms of heat stroke include the following:

• Ataxia or abnormal gait pattern
• Severe irritability
• Slurred speech or inability to form sentances
• Confusion
• Bizarre behavior
• Combativeness
• Seizures
• Loss of consciousness (syncope or "pass out")
• Very late in the process, coma

Note: Heat stroke is where the children will slow down and pass out. They will quit playing and that is not a good sign.

Treatment

The key to treatment and preventing heat stroke is to realize this illness and heat exhaustion are not two separate conditions, but that they are a progression of the same illness.

So the treatment of heat stroke, uses with the exact same treatment as you would for heat exhaustion just with more advanced and aggressive measures. So consider the following as being "in addition to" the treatment for heat exhaustion.

First off: You need to worry about airways with the heat stroke patients. They need to have their airway, breathing, and circulation evaluated (which is an entirely different post on basic Life Support and CPR) and handled accordingly.

High flow oxygen via non-rebreather mask is one of the first line treatments administered to a heat stroke patient in addition to the treatments used in heat exhaustion. And, cardiac monitoring and IV fluid infusion with normal saline (ideally 1 to 2 liters given over the first hour) are also administered.

The patients vital signs need to be monitored continuously (temperature, blood pressure, heart rate, respiratory rate, and  oxygen saturation)

In heat stroke, ice packs are used aggressively in armpits, on the groin, and on the neck, with cold compresses on the scalp and forehead. The sopping wet treatment as demonstrated in the heat exhaustion treatment is preferred here as well, with an effort to keep the patient as wet as possible in a tepid (comfortable ambient room temperature with air conditioning) environment and continuously fanned.

Since it was extremely humid in Michigan that hot day, we opted for the ice packs, a fan, an amazing air conditioner, and a busload of cold water.

The goal is achieve a core body temperature of 102 to 104 degrees F (39-40 degrees C) as fast as possible then to taper the cooling down to avoid hypothermia.

Prevention of Heat Illnesses

The best way to prevent heat illnesses is to hydrate, prevent long periods of heat exposure or to decrease heat, and to acclimatize yourselves slowly to heat.

Hydration:

Seriously people, if you're going to go out in the bristly sun, then you need to be a fish. You need to drink bare minimum 4 to 8 ounces of water or a sports beverage every 15 to 20 minutes that you are out there in that scorcher exerting yourself.

The goal is to drink fluids until your urine is clear. Yes, this means you have to look when you go.

Also, you need to keep in mind that you sweat out your electrolytes, so you need to eat salty foods, such as saltine crackers, pickles, canned vegetables, etc. Why? Well, the salt helps you retain water and you need to replace the salt that you are sweating out, lest you get heat cramps.

And you can always use that 1/4 tsp to 1/2 tsp of salt to one liter of fluid. The World Health Organization recommends for rehydration adding 1/2 tsp of salt and 6 tsps of sugar to one liter of pure water.

Decrease heat:

Wear light-colored, loose-fitting and breathable clothing. In less humid locations, frequently douse exposed skin with water or a cool misting spray. In humid regions, frequently go into air conditioned environments and fan yourself. Avoid direct sunlight whenever possible.

Acclimatization:

You need to allow your body time to get used to a hotter temperature. This process will activate a physiological system called the renin-angiotensin-aldosterone axis which helps your body increase sodium conservation, expand blood volume which helps the cardiovascular system to adapt, and maximizes sweat production. Adults usually take 7 to 10 days to acclimatize to a hotter temperature. Gradually increase the time you spend in the great hot outdoors over the 10 days.

Children and elderly take longer to acclimatize. They can take up to 14 days. (10 to 14 days) Also, people whom are coming from colder climates immediately into hotter ones, such as those vacationing from say Phoenix, Arizona (was a peachy 70 degrees that day with no humidity) to Southwest Michigan (humid 109 degrees) will have a harder time acclimatizing and should gradually increase their exposure over the 14 days.

On the other side of things, it usually takes 1 to 2 weeks to de-acclimatize from going to hot temperature to colder temperature.

Health Condtions

Certain health conditions act as risk factors for increased chances of getting heat illness:

Heart disease. Number one in my book

Lung disease

Skin diseases (such as sclerodermal conditions)

Endocrine disorders (diabetes, hyperthyroidism, obesity, etc)

Neurological diseases (alzheimers, Parkinsons, etc)

Medications (such as heart meds, allergy meds, antidepressants, aspirin, antipsychotics, and recreational drugs)

If you have anymore questions concerning heat illness, please refer to the Wilderness Medical Society whose link is listed in the side bar.

Thank you for reading. TTFN.

Dr. Princeton

The Duck Ages of Folk Medicine: The Good, the Bad, and the Quacks

There I was minding my own business, doing my talk show host thing with my guest wonderful John Milandred, and then the cruelty happened... The technological universe decided to chew up my broadcast and spit it out like a leftover burrito. It was almost as if the botnet of the evil underworld attacked our stream. (Image refers to the book "Slow Death by Rubber Duck" that can be found on http://slowdeathbyrubberduck.com/)

Fortunately, after the whining, belly aching, and beating the computer like a red-headed stepchild in an alien family, my show was saved by Ed Corcoran, the founder of Survivalist Magazine, whom stepped in like a technology superhero. He jumped on the air, covering the broadcast silence with his talk show host expertise. (Ed is the host of the exceptionally rated The Complete Survivalist Show which airs 7 pm to 8:30 pm central time on KPRN-DB the Prepper Podcast Radio Network. You can find out more information on this tech hero on http://www.prepperpodcast.com/Host-Bios.php.)

Anyway enough about the technology gliches and hero talk show hosts, I've got a lot of folk medicine to talk about. Due to the infraction of the technology demons, we lost a bit of valuable time on air and I wasn't able to cover the amount of folk remedies that I had hoped to. (Granted, it was fun having both John and Ed on at the same time, bashing each other like two conquistadors fighting over the prize gold: my audience. ;). My listeners are the best.)

Before I begin describing the best and worst of folk medicine, I'm going to take a tiny detour to discuss the history of advances in medicine.

The History of Medical Stubborn Blindness

I know what you're thinking: "A history lesson? Nooooo!" Oh, come on. You know you love history. Besides, this is all about how medical professionals can be so pigheaded and dumb, when they think they know everything. Everyone loves a good medical community bashing. I'm a doctor and I eagerly get out the sticks looking for the medical pinnata. ;)

Just so you know as if you haven't already guessed, there is a stubborn tendancy within the medical establishment to ridicule its own members if they present ideas different from the mainstream. Oh yeah, its all about the jealousy. Because a lot of those scorned by the medical community tend to be the fathers of true medical advances. Yep, the green-eyed monster strikes again.

A brilliant physiologist named William Harvey was one of the most prominent men ridiculed in this manner. He was the personal physician to King james I. Yep, they definitely hated him. In 1628, he discovered the true circulation of blood. Before him, all medical beliefs on the body's blood circulation came from a dinosaur physician named Claudius Galen (birth 129 AD to 199 AD), whom argued that arteries were just to cool the blood and the heart was the major heat source of which the lungs "fanned" it and discharged "vapors" through the skin. Yeah, there you have it: the heart of our home is the microwave, according to pre-Harvey medicine. This ideology stated that there were two separate blood circulations: the Natural System being the venous blood flow and the Spirit System which was the arterial.

Harvey argued that the flow of blood traveled through the body as if in a circuit, connecting both the venous and arterial systems. For this discovery, he was humiliated and mocked. And it wasn't until after his death, that the medical community of the time finally accepted his discovery as fact.

On my show last night, we discussed the situation surrounding Hungarian-Austrian physician, Dr. Ignaz Semmelwiess (1818-1865). During his lifetime, upwards of 20 to 30% of women and children died during and shortly after childbirth. This was believed to be due to something called "childbed fever" or "puerperal fever," which led to septicemia and death. One of the members of the Clostridium family of bacteria is often accredited with this condition.

He discovered that his medical students that came directly from performing autopsies on mothers that died of puerperal fever to deliver babies from healthly mothers without washing their hands, had higher rates of death among their patients.

So Dr. Semmelweiss argued that doctors should wash their hands between patients. He even went so far as to develop a chlorine wash: a little rough for today's standards of antiseptic handwashes, but still effective. The medical community went for a WWF smackdown on his reputation, ridiculing him to the point of destruction. Heaven forbid that doctors should have to wash their hands! The punk beastards drove Dr. Semmelweiss to a mental breakdown where he died in an insane asylum. All because they were stubborn and didn't want to change what they felt was the standard of medical care. Only years after he died did Dr. Semmelweiss's physician hand hygeine become recognized as an essential advancement in medicine.

The use of nitric oxide in dental work and the use of vitamins in the treatment of diseases and the prevetion of diseases were also met with the same vehement disgust by men too stubborn to look past their own noses.

The moral of the story: Medical advances are always ridiculed by those who are too stupid to realize that something different might just be worth looking into.

Most of the folk remedies that are scientifically proven are still seen as subjects of ridicule by many in the medical community. Granted, there are many old folk remedy wives' tales that should remain just tales, but the remedies that actually work are often lumped in with the quackery as though the modern medical community can't get rid of the stubbornness of their predecessors. Thus the cycle of persecution and unwillingness to investigate different avenues of medicine perpetuates.

Folk Medicine: Fact, Fiction, and Flat Out Quackery

Okay, I know, I should start with the factual evidence behind many folk remedies, but I so have to tell you about some of the funnest quackeries I have ever heard of. I know. I know. You want to refer me to the history of stubborn medical people that I just wrote.... but seriously, you are going to love these ones.

Goose poop for treatment of pimples. I discussed this one on the air. Mmmm mmm mmm! Now, that's a facial mask that brings a whole new meaning to "getting to the bottom of the problem." Fact, pimples are caused by bacteria and oil glands that like to have a party together. Second fact, poop is full of bacteria, most of which is extremely harmful.

This idea comes from the age old wives' tale that dog dung was a good treatment for inflammation and wounds. Yep, some brilliant person in the dark ages decided that rolling around in dog feces would cure everything from baldness to the plague. Another good reason why those times were called the dark ages.

I'm beginning to think that it all started like this:
A nobleman stepped in a big pile of steaming dog poo.

A noblewoman whom he was trying to court sniffed the air and asked, "What foul smell is thus?"

Nobleman lies, as do all those trying to score a chick: "'Tis... uh... um... my medicine for knight's foot. All that jousting needs a... ah... potent medicine, milady." (Yeah, potent as in poo. And thus started the dog dung fad.)

Clipping toenails for a year will cure asthma. This one was perpetuated in the 1800s. This might come from "the toenail bone is connected to the lung bone." LOL. Okay, for the record there is no toenail bone and no lung bone, and contrary to popular belief they are not connected that directly as for toenail clipping to treat asthma.

Biting into a live black or rattlesnake will ensure good teeth and prevent toothache. I love that one. I wonder how much the live snake will appreciate that "remedy." I think it is self-explanatory as to why it fits into the quackery realm.

A sty in the eye can be cured by rubbing it with a live black cat's tail. Now, we got to appreciate the live black animals motif in these folk fakeries. Do you think the cat will be obliging to this quackery?

Okay, enough of the fun quackeries. Now onto the folk remedies that actually work.

Prickly-ash tree bark for oral analgesic. The Prickly-ash tree, also called Zanthoxylum americanum, is a shrub/tree that bears throny branches, aromatic leaves, and a seriously kicking analgesic bark.

As John Milandred said on the Little Prepper Doc show, Native Americans have been using prickly-ash tree bark for toothaches, stomach aches, and inflammation. John indicated that taking an inch of the bark and popping the bitter crud into your mouth produces a numbing effect greater than that of novocaine.

The science behind this is that the bark contains active chemicals such as tannins, ligins, coumarins, and alkaloids. Tannins for example have been proven in studies to have antiinflammatory, mild analgesic, antibacterial, and antiviral properties. Ash tree bark is contraindicated in pregrancy, nursing mothers, and those that have intestinal or stomach ulcers.

A good recipe for prickly-ash tree bark tea is to simmer 1 to 2 tsps (or 5 to 10 grams) of crushed bark in water for 15 minutes or to chew the bark uncooked to relieve tooth pain.

Maggots as a natural form of debridement. The little disgusting wormy fly larvae are the best natural form of debridement in existence. The nasty little critters eat only dead and diseased tissue leaving the healthy living tissue behind. A good story of this was a homeless man came into the ER for foot pain. The doctor looked down at his foot and saw a moving boot of squirming maggots. After almost losing his lunch, the doctor bravely sends in the nurses to clean off the man's leg and give him a good shower. Once the maggots were removed, the tissue left behind on the foot was clean and healthy. The maggots had done their work, preventing gangrene from setting in.

Poultices. The variations in poultices is as broad as an elephant's boxer shorts. Hot oatmeal poultice was used to draw foreign objects out of the skin that are unobtainable by tweezers. Mustard chest poultice is a combination of crushed mustard seed and water (enough to make a paste) with a 4 to 1 parts flour. Place it on the chest of a respiratory patient, changing it every six hours. It has been shown to help in the lymphatic flow of fluid out of the lungs.

Meat tenderizer poultice is a combination of meat tenderizer powder and spit or water to make a paste that is used for sting relief in bee stings. The enzymes in the meat tenderizer breakdown the proteins in bee and wasp stings. Ed Corcoran indicated that honey also can be used for sting relief.

Onions to avoid viral illnesses. One of the interesting findings was that the onion farmers that would sleep a bag of onions next to their beds never came down with the Spanish influenza. Instead, the virus was found in the onions that they slept with. Mmmm.... some people prefer wives, these guys preferred onions. On a more serious note, onions were known for their "drawing power" in folk medicine. In actuality, onions have superb air filtration properties, which collect airborne viral particles, pulling them from the air.

Living the pioneer life. John Milandred, the founder of Pioneer Living, actually practices what he preaches. He lives in a pioneer-style environment without the "technological essentials" of microwaves, plastics, and gas stoves that the rest of us can't live without. He also organically grows his own fruits and vegetables, as well as eats pure and healthy foods. Some people call him an alien because he never gets sick. He has no idea of what the flu is like because he has never had it, nor has he ever taken any vaccinations for it either.

On the opposite hand, environmental researchers Rick Smith, who is the executive director of Environmental Defense in Canada, and Bruce Lourie who is the President of the Ivery Foundation have proven that living the modern-day life might not be so healthy.

In their book, Slow Death By Rubber Duck, Smith and Lourie spend four-days in a "technology-rich" environment eating only foods microwaved in plastic containers, out of cans, and cooked in teflon-coated pans, living on flame-retardant coated furnishings, and enjoying the comforts of synthetic carpets. Prior to their four-day excursion into a surburban condo, the two men had their blood and urine levels of 7 different toxic chemicals measured for baseline. After the four-days, they were measured again to see if the levels of toxins had increased. Sure enough they had tripled and in the case of one chemical known as triclosan, it had multiplied by nearly 2,900.

After the 24-hours of the tuna-eating mercury test, Bruce Lourie started experiencing early symptoms of mercury toxicity such as severe irritability, loss of memory, and anxiety. According to their book, he didn't remember much of that day, which is charcteristic of mercury poisoning. Also his blood results revealed that his blood mercury level had increased far above the "safe" zone indicated by the United States Environmental Protection Agency.

So there is something to be said about the folk remedy of natural and organic living.

It looks like it is time for me to go.

If you didn't get a chance to listen to the Little Prepper Doc show live on Friday, Nov 4th 2011, you can still listen to it on http://www.prepperpodcast.com/Prepper-Doc-Show.php.

Thank you and TTFN.

The 1st Little Prepper Doc Show!

Hello world! Okay, tonight was my first live broadcast on KPRN-DB, the Prepper Podcast Radio Network (http://www.prepperpodcast.com/Prepper-Doc-Show.php).

Yes, it was nerve racking. Seriously nerve racking as if you look up to see a big smelly sumo wrestler was about to squash your head with his bare-naked bum and you have only two seconds to get out of the way.

I was so nervous that I even made a mistake in my speech: I meant to say Coccidiodomycosis (or also called, Coccidiodomycoses) which is a fungus that caused lung infections in California after the earthquake. Instead I said Cryptosporidium which is a protozoan that causes diarrhea. LOL.

Blast those $5000 words! There are so many of them that when you break out into a cold sweat from nerves they start stumbling over each other out of your mouth. Total word salad. Except my word salad was like adding tomatoes to a fruit salad and then adding a spoonful of pepper: it just should never happen.

Anyway, it was fun broadcasting live. From now on, I will have at least one post per show to give further information about the material mentioned in the Little Prepper Doc show.

For those of you that don't know about the Little Prepper Doc show, it runs similar to this blog talking about the ins and outs of preparedness medicine. Next week I will be talking about folk remedies: Do they work and how they work. Please Stay tuned. The Little Prepper Doc show runs Friday nights at 8pm central time.

If you have any questions that you want answered on the show or subjects that you want to hear more about, please email them to disaster_medicine@yahoo.com with "Little Prepper Doc" in the subject line.

Thanks to all of you that listened to my broadcast today. If you missed it, you can download it at http://www.prepperpodcast.com/.

Take care. Love you all!