Act Naturally

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The pharmaceutical industry is producing life-changing and life-saving medicines.  But let’s take a look at what Mother Nature has given us.

by Joe Goldstein, R.Ph.

It’s often been said that there is nothing new under the sun.  Big Pharma is constantly looking for new compounds and creating new chemical entities to fight disease.  I can’t help but think that if we look hard enough, we will find some or all of these chemicals in God’s green earth.  Nature has given us many medicines through the centuries.  I talk about a few in my book Recipe for Health (amazon.com/dp/1622494318), along with the field of pharmacognosy, which is the study of plants and other natural sources of drugs.  Some medicines owe their effectiveness to rocks, minerals and metals, such as sulfur, silver, and even gold.  That may be for another post, but this is all about plants and animals.  They are in no particular order.

One of the best known medicinal chemicals comes from white willow bark, and from the meadowsweet plant.  For more than 2,000 years these have been used to reduce fever and relieve pain and inflammation.  Both were found to contain a chemical called salicin.  Salicylic acid, a chemical that comes from salicin, is where we get acetylsalicylic acid (ASA), or aspirin.  Today we hear of aspirin used mostly to prevent stroke in certain patients, and at low doses of 81 milligrams or less.  When I was growing up, it was commonplace to be given, as children, aspirin for headaches, other pains, and fever, at doses of 650 milligrams.  We no longer give aspirin to children under age 18 years, as it was found to cause Reye’s syndrome in children who have had a recent viral infection.  Reye’s syndrome can be fatal.  Aspirin is still used today by people who suffer from arthritis, and is an effective and very useful medication when used properly under medical supervision.

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Foxglove is a beautiful plant that flowers every two years.  In the 18th century it was given to people who had “dropsy”, now known to be congestive heart failure (CHF).  Digitalis purpurea is the scientific name for foxglove, which gave us the class of drugs called digitalis glycosides.  The best known, digoxin, is a potent drug used today to treat CHF, atrial fibrillation (Afib) and other cardiac ailments.

Chinese medicine still uses plants, animals and insects to make traditional remedies, just as it has for hundreds of years.  Fermenting a particular yeast, and mixing it with red rice, gives red yeast rice, a food eaten in China.  It has also been used as a medicine to improve cardiovascular health.  Red yeast rice has been found to contain important nutrients, and a statin-like substance that has been shown to substantially lower LDL-cholesterol and triglycerides.

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Some people remember growing up and having a tablespoonful of cod liver oil administered to them every morning.  It is a great source of vitamins A and D, and may help ward off some common ailments.  It is also rich in omega-3 fatty acids, known today to help protect from triglycerides.  The omega-3 fatty acids also may help ease joint pain in some people with arthritis and other musculoskeletal problems.  I personally recommend cooking fresh cod.  White fish often have little flavor, but a little creative seasoning will give you a hearty, healthy, and flavorful alternative to that oily spoonful.  Salmon and mackerel are other options from our bountiful seas, to help your healthy heart stay healthy.

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Cinchona is a group of plants native to South America.  In the mid-17th century an extract of its bark was found to relieve the symptoms of malaria.  That extract, quinine, is still used today.  Small amounts of quinine are added to tonic water as a flavoring agent.  In the early 1900’s another cinchona compound, quinidine, was found to treat some types of irregular heart rhythms (arrhythmia), and is still used today.

Paclitaxel is a chemical that comes from the bark of the Pacific Yew.  It was originally used to treat women with ovarian cancer, and is now used in some patients with certain types of breast cancer, and is also used to treat Kaposi’s sarcoma, a cancer found in some people who have AIDS.

Ma huang is a chemical found in the ephedra plant, and has been used in Chinese medicine for thousands of years.  The true chemical name is ephedrine, and has been used to treat asthma and other respiratory diseases.  Ephedrine and its chemical derivatives are not available legally in the United States as a result of passage of the Combat Methamphetamine Act of 2005.  Ephedrine, as well as pseudoephedrine (available in limited quantities behind pharmacy counters), are necessary chemicals in the production of methamphetamine.

Cows eat grass, and also clover, including common sweet clover.  If sweet clover gets moldy, and is allowed to spoil, it produces a chemical called coumarin.  In the 1930’s, a Wisconsin farmer wanted to know why his cows were dying.  Cows that ate spoiled sweet clover were found to hemorrhage, and die.  Coumarin was the culprit.  The spoiling process turned it into dicumarol, which interfered with the cows’ blood-clotting, so they bled to death.  Scientists produced several synthetic chemicals from coumarin and dicumarol.  One, warfarin, was very potent, and was sold as a rat poison.  Warfarin eventually was approved for use in humans, and is taken today by millions of people in the U.S.  How did warfarin gets its name?  It is a derivative of coumarin from the Wisconsin Animal Research Foundation.

There are many other medicines, both old and new, that have their origins in nature.  Watch for future posts.

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Shakin’ All Over

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Uncontrollable shaking of parts of the upper body may be benign, but should be evaluated by a doctor.

by Joe Goldstein, R.Ph.

Essential tremor is the most common movement disorder, and affects some 10 million American adults.  It is an involuntary, and often rhythmic, shaking of one or more body parts, most often above the waist (hands, lips, chin), but may include a side-to-side rocking and foot shuffling.  It is usually not harmful of itself, and is sometimes confused with Parkinson’s disease, multiple sclerosis, or other neurological or neuromuscular disorder.  It may also be mistaken for sudden alcohol withdrawal.  Because it must be differentiated from other pathologies, it is very important that it be evaluated by a physician.

One of my neighbors has essential tremor.  He and his family call it “the shakes”.  It was noticeable 30 years ago, and it is much more so now.  He used to have fine tremors in his hands, which have greatly increased over the years.  As is typical with essential tremors, one hand is more affected than the other.  In the three decades I have known him, he has rocked from side-to-side when he stands and talks with us.  He was a blue-collar worker all his life, working in the public sector in the transportation industry.  He is now 75 years old.  He’s not helpless.  He uses a snow blower when necessary, rides a bicycle every day, works out with free weights, mows his lawn in the warmer months, and is very sociable.  However, he has difficulty holding a glass, or a fork, and fine work is very difficult, or even impossible.  He used to perform all the mechanical work on his cars, but is now unable to because of his hand tremors.  More recently, his chin has begun to show signs of tremor.

What causes essential tremor?  Nobody really knows.  The term “essential” indicates it is not caused by another disorder.  There is a type of essential tremor called familial essential tremor, which is believed to be inherited.  The specific gene associated with this has not yet been identified.  Maybe we can compare essential tremors to an automobile engine.  Sometimes the engine misfires, and the car shakes.  With essential tremors, it’s possible that the nervous system “misfires”, sending signals to the body parts that cause the surrounding muscles to “twitch”.  This rapid twitching turns into tremors.  The severity of the tremors often increases with age.  Older people tend to have more musculoskeletal issues anyway, so essential tremor may be more difficult to diagnose.

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Medication may be prescribed to try to treat essential tremor, but there is no known cure.  The first line of medication is a class of drugs called beta-blockers, which interfere with certain nerve impulse transmission.  Beta-blockers are used to treat high blood pressure (hypertension), but are also used for other disorders, including some types of headaches.  Actors and other performers sometimes take the beta-blocker propranolol (INDERAL) to relieve performance anxiety before they go on stage.  Like every other medication, beta-blockers have side effects that include drowsiness, lowered pulse (heart rate), decreased blood pressure, and erectile dysfunction, and more.  Beta-blockers should be used with caution in people with asthma and other respiratory disorders.

Another commonly used drug to treat essential tremor is primidone, an anti-seizure drug often used to treat epilepsy.  Primidone (MYSOLINE) also has side effects, including drowsiness, dizziness and nausea.  Both primidone and the beta-blockers should be taken with caution by people who drink alcohol.

Alcohol is actually another treatment for essential tremor, and people who are afflicted can sometimes mask their symptoms in social settings by having a drink or two.  Alcohol is not an ideal treatment, as it causes impairment, and may also result in tolerance, requiring increasing amounts of alcohol to be effective.

Topiramate (TOPAMAX) and gabapentin (NEURONTIN) are two other drugs that may be prescribed to treat essential tremor, although they are indicated for other disorders.  They may cause drowsiness.  They should be used when other treatments fail, or are contraindicated.

Onabotulinum toxin (BOTOX) may be of some use in patients with essential tremor.  Onabotulinum is injected every three months, and is thought to reduce tremors by weakening surrounding muscles.  Onabotulinum may not be covered by some insurance plans, and costs hundreds to thousands of dollars for treatments.

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In some cases, surgical intervention is indicated.  Deep brain stimulation is the insertion of a long, thin probe into the thalamus, the part of the brain thought to be involved in the tremors.  A device implanted in your chest sends impulses to the thalamus, and blocks the signals causing the tremor activity.  Deep brain stimulation comes with its own side effects and risks, and should be carefully discussed with your doctor.

As stated before, essential tremor itself is usually not harmful, but it can interfere with some of the activities of daily living.  Patients may not be able to tie their own shoelaces.  It is difficult to drink fluids while holding a cup or glass.  Using a fork may be difficult, especially if using it to hold down food while trying to cut it with a knife.  Some people find it easier to use oversized utensils, or ones that are weighted down (especially cups).  Writing may be especially difficult.  Some people with essential tremor may become withdrawn, and depressed.

What can someone who has essential tremor do to make things better?  Sometimes avoiding caffeine can make the tremors less pronounced, or less frequent.  Although drinking alcohol can be a treatment, it is best to keep alcohol use minimal, as tremors, if they go away for a while, often come back stronger.

Try to avoid or reduce stress, which seems to bring on stronger and more frequent tremors.  Learning and employing relaxation techniques, even controlling your breathing, can often help to reduce the severity of tremors, and decrease their frequency.  Try to adapt to your situation.  If your right hand shakes more, then learn to use your left hand for some tasks.  Use the speaker on your home and cellular phones, instead of holding them to your ear.  Avoid writing when you can, including paying bills with checks.  Use on-line banking and shopping if you feel comfortable doing so.

Essential tremor is more common than most people realize, and can have similar symptoms to other disorders.  Only by consulting with a physician can a correct diagnosis be made, and proper treatment begun. Shaking hands should be something you’re happy to do, not something you can’t undo.  Give yourself a fair shake.

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I Can See Clearly Now

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Sudden, unexpected pathology to your eye can be life-changing.

by Joe Goldstein, R.Ph.

My friend Keith had surgery last week to repair a hole in the retina of one eye.  The retina is a thin tissue at the back of your eye that has been compared to the film in a camera, or the sensors of a digital camera.  Normally, light enters at the front of the eye through the cornea, the clear, domed part that covers the pupil.  The rounded cornea slightly bends the light, which passes through the pupil and enters the lens of the eye, which bends it more.  The light passes through a jelly-like substance that fills the eye, called the vitreous humor.  Ultimately, the light falls on the retina, which is really the part of the eye that sends electrical signals to the brain, which translates the light into images.  That’s how we see.  What caused the hole in Keith’s retina?  Most likely the vitreous humor at that area separated from the retina, causing the hole.  Some diseases, such as diabetes, make people more likely to have this happen.

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Each part of the eye is marvelously designed to function together with other parts to provide the best possible vision we can have.  Sometimes, things go wrong, even at birth, and people are born without sight, or with diminished vision.  Visual problems can range from any issues within the eye itself, to problems with tears (see “96 Tears” in this blog), to eyelid diseases, to eye muscle disorders.  Other disorders of the body may affect the eye and vision (diabetes, multiple sclerosis, and more).  Fear of blindness is one of our greatest fears.  The eye is designed to protect itself, and God, in His wisdom, gave us two of them, in case one failed.

I want to give you a sense of the simplicity, and the complexity, of the eye.  Much of what I write here is fact.  Some of it is theory.  I’ll let you know which is which.  I would color-code it, but some of my readers may have some form or degree of color blindness.  Color blindness is often an inherited trait.  As many as 8% of men are color blind, but only 0.5% of women are genetically affected.  Chemical or other traumatic injury to the optic nerve can also cause some color blindness.  As we age, our color vision is often altered by the development of cataracts in the lens of our eye.  When (if) the cataract is removed, by surgically removing the entire lens, color vision is most often fully restored, and can be quite a dramatic change for a person.  Compare it to the movie “The Wizard of Oz”.  The first part of the movie, taking place in Kansas, is in black & white.  When Dorothy opens the door of her house after it lands in Oz, she sees everything in vibrant colors.  Cataracts can dull color vision substantially.  By the way, cataract extraction is the most common surgery performed in the U.S. according to the National Institutes of Health.  The American Academy of Ophthalmology informs us that nearly 25 million Americans have some form of cataracts, and 2 million cataract operations are performed each year.

The usual process is that light enters the cornea in a straight line.  The cornea bends the light as it comes in, and directs it onto the lens.  The pupil is the black hole in the center of the eye.  It can be constricted (very small) or dilated (wide open), or anywhere in between.  The size of the pupil is governed by the iris, the colored part of your eye.  Iris color is determined by your genes, and also by some disease states.  Behind the iris is a space in which a clear liquid flows, called the aqueous humor.  It’s function is to provide the front part of the eye with nourishment, and remove any waste materials.  The rest of the body is provided for by circulating blood, but since the front of the eye must remain clear, blood vessels can’t be there, or they would interfere with our sight.

Next, we find the lens of the eye, often called the crystalline lens.  This organ changes size and shape with the changing needs of your vision.  Light focused on the lens is re-bent and directed to the retina, at the back of the eye.  But let’s spend a few minutes talking about the lens, since it composes a major part of our visual pathway.

The lens should be clear and flexible.  Some diseases make it more rigid, and make it lose its clarity.  Age also does the same thing.  Typically, the lens loses the ability to change its focusing power, and when we reach our 40’s and 50’s, it becomes fixed in a focus that is usually just beyond out outstretched hand.  This is called presbyopia (“old-sightedness”), and it affects almost everyone.  Some people who are nearsighted (myopia) aren’t as affected as the rest, and those of us who are farsighted (hyperopia) tend to need reading glasses sooner.

The lens may become cloudy, or have areas that are opaque.  These are called nuclear cataracts, meaning they are in the central part of the lens, called the nucleus.  They interfere with light getting to the retina.  They can range from yellow to brown in color. What causes them?  Great question.  Diabetics and smokers have a higher incidence of cataracts, as do people who live near the equator.  Here is where my theory comes in. Grab a hold of your seat, because it can get a little convoluted.  And some of it may be contrary to what other sources claim.  Another type of cataract, called a posterior subcapsular cataract (PSC), is in a different field of vision, and usually causes some glare, most often at night.

Ultraviolet (UV) light, which comes from the sun, is the light that enters our eyes.  Ultraviolet light can damage human tissue.  It is what causes sunburns.  It also helps us to stay healthy, and alive.  But it doesn’t belong directly in our retinas.  I believe our eyes use a very potent, naturally occurring chemical to protect our retinas from UV light: vitamin C.  Aqueous humor has one of the highest concentrations of vitamin C in our bodies.  Aqueous humor normally is circulating.  It is not like standing water.  I believe that a sufficiently high level of vitamin C protects the rest of the eye from UV damage, a process that takes many, many years.  A long-standing debate is why there is a higher incidence of cataracts in the southern United States than in the north.  Is it because people there live closer to the equator, and are exposed to more sunlight?  Or do more older citizens move down South, and the higher incidence is age-related?  Let the epidemiologists work on that.   When the level of vitamin C in the aqueous humor drops, I believe the vitamin C begins to accumulate in the lens.  Throughout our lives, our levels of vitamin C, as well as other essential nutrients, fluctuates.  Stress depletes vitamin C.  Smoking depletes it.  Sickness lowers it, as does surgery, trauma, emotional distress, etc.  Diabetes causes several changes to our body that deplete vitamin C.  Our parents and grandparents showed great wisdom in having us drink orange juice, a good source of vitamin C.  I believe that these episodes of stress, strewn over six or seven decades of life, cause vitamin c to accumulate in our lens, which is the body’s way of clouding our vision, thus protecting our retina.  In an experiment many years ago, I obtained lenses that had been surgically removed, and placed them in both clear and amber bottles.  I also placed them in different solutions: tap water; tap water with vitamin C; vitamin E oil; and even vodka!  I thought the results were interesting.  One lens turned brown: the lens in vitamin C solution in a clear bottle.  You can draw your own conclusions from that.

The light that has passed through the cornea and lens now is focused on the retina, after passing through the vitreous humor.  The millions of sensors in the retina change the light into electrical impulses that are transmitted to our brain via the optic nerve.  The brain translates it all into images.  By the way, each of our eyes has a blind spot, called the physiologic blind spot.  It’s where our optic nerve comes into our retina.  There are no sensors there.  Getting back to Keith, a retinal hole is usually in a part of the retina called the macula, which is responsible for detailed vision, including reading and writing.  It is what is affected in the condition called senile macular degeneration (SMD), also called age-related macular degeneration (ARMD).  People with ARMD often can’t see well enough to read, or write, or sign their names.  They usually don’t walk into things, but may have trouble getting around.  They surely should not drive.

Keith did well through his surgery, which included removing some of the vitreous humor from his eye, and injecting a gas bubble to replace it.  The gas bubble has to stay in place for one to two weeks so the area can seal.  The bubble eventually dissolves, and vitreous humor, or any replacement that the surgeon may have introduced, keeps the seal in place.  Patients must stay in a face-down position.  Specialty medical companies rent and sell face-down chairs for patients who have had this type of surgery.  They come with options and accessories to enable people to eat, sleep, watch television, and perform daily routine activities.  In a car, Keith sits with his chin to his chest.

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Keith will probably be back to work in a few days.  The irony is that Keith works in the optical industry.  He told me that being monocular (vision in one eye) was disturbing, a sentiment I can appreciate, as I have been monocular since I lost most of the vision in my left eye in mid-2016, due to a stroke that affected my optic nerve.  Keith also does not like having no depth perception.  He’ll get over it.  His blurred vision is fading, and he is making great strides toward again having clear, binocular vision.  He wore a plastic or metal shield over his operative eye the first day or two, and wears it at night so he can’t rub his eye, or poke the corner of a pillowcase in it.

Keith will lead a normal life, but will need to control his activity and his diet.  He will need to be a little more aware of what’s going on around him, a little more wary of potential traumas.  He will need to avoid stress.  He has learned what it’s like to be up tight, and out of sight.

 

 

 

“…’Cause if You Feel My Leg, You’re Gonna Feel My Thigh”

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The last (hopefully) installment in my latest surgical saga.

by Joe Goldstein, R.Ph.

A couple of previous posts (“Angie”, “Don’t You Feel My Leg”) chronicled my journey leading up to my recent surgery, done this past Monday.  It was supposed to have been on Wednesday, but my surgeon wanted to leave to spend a few days (and probably Easter) in his home in Miami.  As he said to me, “better to be in 88 degrees than 58 degrees.”  If our roles were reversed, I would have done the same!  And to his credit, he did not want to operate on me and then jet off.

Early Monday morning I checked into the Day-Surgery department.  I know some people who work and volunteer there, but I was unconscious before they arrived at the hospital.  Still, I knew I would be in good hands.  I’m sure I was nervous, but I didn’t feel it.  In a few paragraphs I’ll offer a critique of my time there, but let me say up front that all the people I encountered and interacted with were professional, and compassionate.  All were most concerned with my comfort and well-being.  I have only good things to say about the hospital staff.

I have been critical of this hospital in the past, and I still am critical of the physical plant.  The building is old, and is showing its age.  The parking situation is abominable.  The nurses and support staff are overworked, because of staffing shortages.  Announcements are made over the loudspeaker system to let the staff know what the patient census level is, so they may prepare for an influx of sick and injured people.  A couple of weeks ago I sent a 3-page letter to the hospital CEO telling him what I just wrote here, but with more detail.  I have yet to receive a reply.

When instructed to, I disrobed, and donned a hospital gown.  I had always been told, since I was a child, that these gowns were called “johnnies”.  I never knew why, so I decided to investigate.  According to some sources, the term “johnny” is regional, and comes from the northeast part of the U.S.  Being from Maine, it makes sense I would have heard it there.  The common thought is that they are called “johnnies” because their design makes it easier to use the bathroom (john).  Actually, their design makes most body parts more readily accessible to medical personnel.  The only improvement I would make in their design is to replace the ties in the back with Velcro strips.  I know this has been tried, with mixed results.  I imagine Velcro would be easier for those with arthritis, or with reduced grip strength for other reasons.  It is probably also more expensive to make and maintain.

I lay on the gurney, surrounded by people.  My surgeon was there, along with a nurse, as well as a surgical resident.  I had four professionals from the anesthesia department asking me questions about my past anesthesia history, my current medical conditions, and any anatomical anomalies they should know.  They inserted an intravenous (IV) line, and administered a little sedative to relax me.

The surgery involved bypassing a major artery in my leg that was too narrow, and too hard (calcified) to expand with a balloon, or open with a stent.  I would have a plastic or Dacron tube inserted in my leg, and sutured both above and below the most narrowed part of the artery.  I would have two substantial incisions, one in the groin and one above the knee.  It was difficult for me to get a clear explanation of the length and size of these incisions.  My surgeon did not readily explain these details to me.  What was new and mysterious to me was routine for him.  Others agreed he was not the greatest communicator, but his skills as a surgeon are excellent.  That was nice to hear, because I went to see him for his surgical talent, not his eloquence.

My next memory is of waking up while being wheeled into a room in the Cardiovascular Unit (CVU).  I was greeted, and asked if I had any pain.  I have a fairly high pain tolerance, and I asked what my pain orders were.

I am a big critic of opioid pain medication.  Here’s why:  Opioid drugs are highly addictive.  Anyone who is not aware of that has not heard or read the news in the last five years.  Their head has been in the sand, or elsewhere.  My orders were that I could receive 10 milligrams of oxycodone by mouth “any time”.   I won’t say that’s irresponsible, because doctors want to have their patient in as little pain and discomfort as possible.  But let’s start lower on the scale, and work up if needed.  Also, speaking as both a pharmacist and as a patient who has taken opioid pain relievers, I can truthfully tell you they don’t relieve pain.  They make you not care about the pain you have.  They alter your perception.  I refused oxycodone, and, as previously discussed with the surgical team, began a regimen of alternating low doses of acetaminophen (Tylenol) and ibuprofen (Advil).  This gave me the option of increasing the strength of each dose, and of shortening the time between doses.  I also had the option of taking oxycodone if I really felt I needed it.  I did not.

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Surgery went well.  The purpose of my having this femoral-popliteal bypass was to restore adequate blood flow to my left lower leg.  It did the job, as my postoperative pedal (foot) pulses are strong.  My surgeon expected me to be in the hospital for two nights, but on the second day he said I was doing so well, that I could go home.  In his words, they were now only “babysitting me”.  I am at home now, and able to get around with some minor discomfort.  I have further reduced my dose of pain meds, and have increased the time between doses.  I still have some sharp pain if I move the wrong way, but I can take my dog for walks, climb stairs, and perform most of the activities of daily living.  Tonight my excitement will be my first shower since surgery.  My surgeon told me he used stainless steel staples to close my surgical wounds, and reassured me they will not rust!

The staff, especially the nursing staff, were all very good and very attentive.  I left the operating room with a Foley catheter draining my bladder.  Of all the things in this world I do not like, having a catheter removed is high on the list.  But to his credit, my nurse removed it with minimal discomfort to me.  I was free at last!  (Except for the oximeter, heart monitor, and IV antibiotics.)   In the CVU, there is one bathroom for the use of more than a dozen patients.  That’s a bad ratio, and that needs to be changed.  Some rooms have a corner where a pull-out toilet sits under a sink.  Mine did not have one.  I had a male urinal and a commode.  I used neither.  I was told that most of the patients on this unit are much sicker than I, and most do not get up and walk.  I still think more restroom space is needed.

One big criticism I have is of the hospital food.  Most of it is tasty enough, but it is not necessarily nutritious, and not always appropriate for the patient.  I missed my coffee.  I was served de-caf, but I hate decaffeinated coffee.  I asked for regular coffee, and was told it was not allowed on the CVU, as the caffeine could elevate a patient’s blood pressure or heart rate.  Even though I was not there as a cardiac patient, I still could not have it.

I have Type 2 diabetes, and need to limit my intake of certain carbohydrates.  I know that rice and pasta are my enemies.  Baked potatoes are my friends.  My meals were filled with carbohydrates, including orzo, pasta, mashed potatoes, rolls, pie and cakes.  And let’s not forget the waffles and oatmeal at the same breakfast.  For one meal, even though the meal card indicated diet beverages, I was given regular cranberry juice.  The second ingredient is high fructose corn syrup, also known as SUGAR!   Note the meal card pictured contains noodles, Shepard’s pie, crackers, tapioca dessert, and diet CJ (oops!).

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I hope I have made it clear that I have only good things to say about the people who cared for me.   The deficiencies and minor mishaps I encountered are essentially small human errors, but they could have dramatic and major results if not corrected.  Maybe because of my training and experience as a pharmacist, I am more aware of some of these incidents.  Maybe it’s paranoia, or maybe it’s heightened awareness.  The popular saying in business is “caveat emptor”—let the buyer beware.  We should apply the same saying to our health care.  We are all consumers of health care services, and goods.

My wife noted that the graham crackers she eats are getting just a little bit smaller, but cost the same.  Yogurt that used to be sold as a six-ounce cup is now 5.3 ounces.  Popsicles, formerly sold in a box of 20, are now sold in an 18-pack for the same price.  Healthcare faces these same costs, and must make decisions to save money or increase revenue, always with an eye to the bottom line.  It is up to us—up to YOU—to make your feelings known when the reduction of services and goods in healthcare affect your care.  Ask questions.  Don’t be afraid of challenging your doctors or nurses or hospital administrators.  Let them know you respect them as professionals, and continue to challenge them.  All hospitals have (or should have) a patient advocate.  If you feel you are not being treated correctly, or with dignity and respect, insist on a visit from him or her.  Corrections are made when consumers point them out, or when tragedies happen.  Please, point them out.

 

Don’t You Feel My Leg

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Hospital testing before major surgery can be frustrating.  Who makes the rules?  Are they reasonable?

by Joe Goldstein, R.Ph.

I’m having surgery on my left leg next week.  By the way, do you know how difficult it is to find clip art of the left leg?  Clip art of the right leg is abundant!  Anyway, a couple of days ago I went to the hospital for pre-admission testing, which consists of blood tests and an electrocardiogram (ECG or EKG).  An ECG measures and records the rate and rhythm at which your heart beats, and can detect minor electrical disturbances in your heart through up to 12 wires and electrodes that are attached to your chest, arms and legs.   I had an ECG within the past few weeks, so that was waived.  The hospital demands it be done if your last ECG was done more than three months ago.

I was entered into the hospital’s new computer system, and after a lengthy interview with an operating room nurse, in which my complete history of illnesses, surgical procedures, allergies, and medication use was obtained, I was given an order form for the laboratory and directed to that department.  Before I left, I had some questions.

I was told that the ECG was waived, as explained above.  Why?  My ECG could change at any time, as can anyone’s.  I’m particularly at risk, because I had a five-vessel coronary artery bypass with grafts more than a year and a half ago.  Additionally, I had a single episode of atrial fibrillation (A fib) about eight years ago.  A fib is the term used when the two upper chambers of your heart beat erratically.  At the time, I had a severe spinal infection, and my fever was elevated to nearly 105º F, which can cause A fib.    It happened once, eight years ago, but that diagnosis has followed me–haunted me–even though it has not happened since.

I mention this, because I consider myself a cardiac risk, with a heart that could have significant medical issues at any time, including electrical conduction problems.  When I drove to the hospital, I anticipated having ECG leads painlessly attached to the appropriate parts of my body, but that didn’t happen.  ECGs are painless, unless you have a lot of hair which gets pulled when the adhesive electrode pads are removed.

I was also told I would need blood drawn for several tests, including a complete blood count (CBC), a Basic Metabolic Panel (BMP) and also to type and screen my blood so that I may have the correct blood handy should I need it transfused.  A BMP measures certain chemicals in the blood, including sodium, potassium, calcium and glucose (sugar).  I also needed another test called a PT/INR, which measures the ability of my blood to clot.  I was told the CBC, PT/INR, and BMP needed to be dome within 30 days prior to surgery, and the type and screen was required within 14 days of the operation.

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I had all the above lab work done 26 days prior to surgery, yet I was told it still needed to be repeated.  Why?  Because the doctor ordered it!  That was the disclaimer for all the things I didn’t want to do.  And even if the doctor ordered it, I could refuse it.  I eventually gave in, realizing that this nurse, her supervisor, the secretary who registered me, and the lab tech all were just doing their jobs, and giving these folks a hard time could come to no good.  I decided any questions or complaints would need to be directed to the surgeon.

Perhaps my biggest gripe is needing to have my blood typed and screened.  I suppose I can understand the need to screen my blood for antibodies, as it’s possible I may have developed some new antibodies in the past 26 days.  But why check my blood type?  That hasn’t changed in decades!  This hospital has records of my blood type from 26 days ago, as well as from previous surgeries, blood donations, and blood transfusions.  I asked, but never received a satisfactory answer.  “The doctor ordered it.”

Part of me wants to believe that the hospital is going to great lengths to make sure I am strong enough to withstand anesthesia and surgery, and I’m grateful to anyone who assists in keeping my heart beating on its own, and my lungs spontaneously inflating and deflating as they have always done.  Another part of me wonders if all this work is being done to generate revenue, and help increase the bottom line for this for-profit establishment.

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The testing is done, and  everyone I interacted with in the hospital is happy just to be rid of me.   I’m hoping to be happy next week, and after, anticipating a successful surgical result.  I don’t intentionally try to be antagonistic.  Maybe I came across that way because  I needed to regain some level of control.  I needed these choices to be my choices, and not those of the doctor, or of hospital policy.  Patients, especially in a hospital setting, give up a lot of control.  And they give up their modesty and their dignity.  There is nothing dignified about an adult male having a urinary catheter placed, or walking down the hospital corridor, struggling with an IV pole with one hand and holding the hospital gown closed in the back with the other hand.

Most policies regarding patient care in hospitals are designed to preserve and promote patient safety and well-being.  Some policies are designed for the safety of the staff and visitors.  Some are not policies, but are directives from a corporate office, or from a governing body.  Not all the policies make sense, at least not to me.   I welcome anyone to help increase my knowledge on the subject.  Please feel free to comment on this, or on any health-related topic.   I can use the help!

 

 

From You, I get Opinions; From You, I Get The Story

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When clinicians and caregivers fail to follow through, or disagree, feelings and egos can get hurt.  Sadly, so can patients.

by Joe Goldstein, R.Ph.

My wife, Ellen, is a registered nurse.  She has worked in several different patient settings in her time, including orthopedics, pediatrics, family planning, medical/surgical, and home health.  She is highly skilled, and has good clinical judgment.  For the past decade she has worked in an independent living facility that is populated by mostly affluent, intelligent folks who own their own condos.  Some have pets.  Some are married, and some are widowed.  Most are highly educated, and were, or still are, successful in business, industry or education.  Some practiced law (or still do), and some practiced medicine.  Most have lived to their ninth decade or beyond!

Ellen is very discreet, and very protective of the privacy of her patients.  She sometimes tells me stories about them, but will never reveal any information about them, except, perhaps, their gender and age.  Saying that someone there is a man in his nineties narrows it down to about 45% of the population.  Ellen occasionally tells me about a patient scenario she thinks I may find interesting, or that particularly frustrates or angers her.

Ellen recently told me about a patient who was admitted to the hospital for some unknown (to me) acute medical problem.  It might have been a urinary tract disorder, as those are common in her patient population.  That’s not important.  What is important is that the patient (I’ll call him “Ben”.  I don’t know if that’s his name) was sent home, back to the facility, with an order for his anticoagulant (“blood thinner”) medication, but no prescription.  On the weekend.  Nurses are not permitted to begin, change, or stop a patient’s medication without orders, but they need a prescription to send to the pharmacy.

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Prior to his hospital admission, Ben had been taking the drug Aggrenox, a combination of two chemical agents.  While in the hospital, Aggrenox was stopped, and Ben was given Eliquis, a different type of anticoagulant.  Both require a prescription.  When Ben returned home, he brought with him three doses of Eliquis, with no orders for more.  Both drugs are used to treat multiple conditions, such as thromboembolic stroke (a stroke from a blood clot) and also to prevent a recurrence of the disorder.  I don’t know why Ben needed anticoagulation therapy.  It’s not important to this story.

What is important is that Ben was sent home without any medication.  Sorry, that’s wrong.  He was sent home with three tablets.  It’s taken twice daily, so he had enough for 1 1/2 days.  He had instructions to continue Eliquis, but was not provided with a prescription for it.  He was not instructed to restart his Aggrenox.

Why would his treatment have been changed from Aggrenox to Eliquis?  It’s possible his doctor in the hospital felt that Eliquis was a better choice than Aggrenox for Ben’s medical condition.  Maybe Eliquis was better during the acute phase of whatever brought Ben to the hospital.  Maybe Aggrenox was contraindicated during that time, because of potential drug-drug interactions with whatever treatment Ben was receiving while an inpatient.  Or maybe Aggrenox and Eliquis were equally effective for Ben, but Aggrenox was not on the hospital’s drug formulary, and Eliquis was less costly (to the hospital) because of contracts with the drug manufacturer.

Ellen, being the good nurse that she is, called Ben’s doctor to request a prescription be called to Ben’s pharmacy.  It being the weekend, Ben’s doctor was not on call, but the covering clinician responded to Ellen.  That person’s order was to go back to using Aggrenox for the weekend, and to then call Ben’s regular doctor on Monday.

The clinician may have had some very good reasons for not continuing Eliquis.  Maybe Ben’s health insurance plan wouldn’t pay for it, or it was a high tier medication cost.  Maybe Aggrenox was a better choice for Ben’s original condition.  Maybe the clinician didn’t want to make a choice, or knew that Ben had stockpiled several bottles of Aggrenox at home, and didn’t want it to be wasted.

The reasons, while important, weren’t what Ellen was looking for.  She wanted—no, she needed—orders from a licensed clinician.  She shouldn’t have needed to look for anything.  Ben should have been sent home with clear orders for any limits of activity, any dietary orders, any orders for physical and/or occupational therapy, and—yes—any medication orders.  The doctor who wrote Ben’s discharge orders should have been more thorough.  The nurse who (hopefully) reviewed the orders with Ben should have questioned it.  The orders were written, but only three tablets were sent home with Ben, and no prescription was given.  The covering clinician would not give the prescription for Eliquis, even though the orders were written for it.  Ellen is very thorough, and usually makes her points in a concise and logical manner.  I don’t know if, on this occasion, she was forceful, or if the covering clinician sought any more information.

Ben’s story is not unique, nor is it unique to  this type of facility.  This kind of omission happens daily in nursing homes, hospitals, care facilities, and pharmacies across the country, and all over the globe.  Residents probably write most of the discharge orders for inpatients being discharged.  I don’t mean to single them out, but they have three strikes going into the game.  They write the bulk of the orders.  They are still in training.  They are human.

Several years ago I was discharged on a weekend after having spent a week in the hospital afflicted with osteomyelitis, a bone infection, of my lumbar spine.  I was to self-administer an IV antibiotic daily for the next six weeks.  A visiting nurse sat at my dining room table with me and taught me how to take care of the IV.  She also reviewed my other medications.  I was taking far more drugs then than I do now, and five of the orders on my discharge summary, written by a Resident, were in error.  I told her to just call the attending physician.  She balked.  He was a specialist, apparently with a reputation for not wanting to be disturbed, and it was Sunday…

I arched what was left of my back!  I didn’t care who he was, or what he liked!  I personally had always found him to be very pleasant and very approachable.  I told her if she didn’t call him, I would.  She hesitated, but made the phone call.  He answered back, and gave her new orders that coincided with what I had told her.  At my first post-op appointment, he entered the room, closed the door, and sat at his desk facing Ellen and me.  I knew who the Resident was who had written the discharge orders.  My specialist began his conversation by saying, “She really is a very good doctor, and I told her she would make mistakes, but to try to not make any more drug errors on a pharmacist!”

He was right.  Everyone makes mistakes.  We rely on our professional caregivers to use their judgment to minimize or prevent errors.  Attending physicians review the work of the Residents.  Nurses review their work.  And pharmacists review them all (I’ll take some heat for that one).

People don’t like to be questioned.  Two incidents from my past professional practice come to mind.  The first was while working for a large pharmacy chain.  One evening a gentleman gave me a prescription for his six month-old daughter.  The drug was for a potent steroid cream.  It was approved for once-a-day use on adults 18 years old or older.  This prescription was written to be used three times daily.  I phoned the physician’s office and asked his answering service to have him return the call.  A few minutes later the covering doc called back, and began by telling me it was a toll call for him.  For you younger readers, phone calls outside a local calling area used to cost money.  I ignored that, and voiced my concerns.  He told me they were reputable physicians, and to fill the prescription as written, then hung up.  Dad heard my side of the conversation, and was a little upset.  I asked why baby was using the cream, and was told it was for dry skin.  I refused to fill the prescription and returned it to dad.  He was grateful, and planned to address the doctor.  I told him if he didn’t fill the prescription that night, he could always use a little Vaseline.

The second occurred a few years later while working in a health center.  A patient dropped off a prescription for an injectable combination of drugs that was used to treat erectile dysfunction.  The clinic protocol was for the pharmacy to bring a test dose to the urology clinic where the patient received the drug, and waited to make sure no harmful side effects happened.  I phoned the prescribing physician and waited for his return call.  Minutes later the phone rang.  It was him!  I explained that I had called because of the variation from protocol, and he responded, “I’m phoning you from my car, and this is costing me money!  Just give him the prescription!” and he terminated the call.  As I was explaining to the patient why I would not fill his prescription, Dr. F.  called back.  To his credit, he apologized to me, said I was right, and directed me to have the patient return to clinic to schedule a test dose.

There have been many more like incidents in my practice of pharmacy, and in those of tens of thousands of other pharmacists, nurses, and other health professionals.  Mistakes happen.  Everyone makes them.  We just hope that we catch the big ones, and only the small ones slip by.  We all should appreciate and respect each other: physician, nurse practitioner, physician assistant, nurse, pharmacist, lab tech, radiology tech, aide, dietician, and more.  Remember, it should always be about the patient.

According to the American Pharmacists Association, pharmacists deliver pharmaceutical care, which “…is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient’s other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective.”   

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Work in concert?  I hope someday I hear a symphony.

 

 

 

Call Me

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ThePassionatePharmacist looks at the health benefits, and health risks, of cell phones.

by Joe Goldstein, R.Ph.

Sundown to sundown, March 9-10, 2018, is the National Day of Unplugging.  I suppose it’s oxymoronic for me to be writing this on a day in which we’re encouraged to abandon our devices, especially our cell phones, at least temporarily.  My compromise is to look at, and report on, the health implications of cell phone use.

I’m old enough to remember when cell phones were actually used just as phones.  The first such device I owned was a bag phone.  Literally a telephone in a bag, it hung on my shoulder like a pocketbook, it’s large collapsible antenna extended above the top of my head when I wanted to tell my wife when our daughter or son scored a goal at a soccer game, or get a message from her if she needed me to stop at the store.  The bag phone was just that—a phone.  Nothing more.

Cell phones are rarely used as telephones today.  Even their advertising fails to mention them as phones.  They are promoted for the quality and features of their cameras and for their storage capacity.  They are used to send and receive data, which can be anything from photos on Instagram to news reports of dramatic national events.  They keep us in touch with one another, but we never speak into them.  A few years ago the dean of MCPHS University in Worcester, Massachusetts, addressed alumni and educators by saying that they were challenged with teaching the first generation of students who “talk” with their thumbs.  Texting has opened a new world of communication, and perhaps has set in motion the closing of an old one.

What about direct health effects to humans?  Cell phones and cell towers emit a type of non-ionizing, electromagnetic radiation called radiofrequency energy.  This is at a low frequency, or low energy.  Ionizing radiation is at a high frequency, and includes things such as x-rays and radon.  These types of radiation are absorbed by the tissues of the human body.  We all know that repeated and/or prolonged exposure to ionizing radiation can be harmful, and includes the development of certain types of cancer.  Low frequency radiation, the kind given off by cell phones, has NOT been found to cause any types of tumors,  according to reports from the National Cancer Institute (NCI).

The studies reviewed by the NCI have looked at cell phone use relative to the development of malignant brain tumors (gliomas), and benign tumors such as parotid (salivary) gland tumors, meningiomas (brain and spinal cord tumors), and acoustic neuromas (tumors of the nerves that allow hearing).  They conclude that there is no substantial, science-based evidence, that cell phone use causes any of these.

Like microwave ovens, which also use low-frequency radiation, cell phones can cause heating of the area next to the phone, such as the ear and head.  There is no evidence that this causes any harm.  Some studies have even shown that cell phone use can affect the amount of glucose in your brain, but the reports are conflicting.  Any effects that cell phone use may have would be dependent on the age of the phone, the length of time used, and proximity to the area of the body (ear, head, thumbs?).  The only solid conclusions that any of the cell phone studies have come to is that there are no conclusions (more research is necessary).

There are some definite health hazards associated with cell phone use.  Almost all involve the use of cell phones while driving, especially by young people.  Some statistics, from the National Safety Council and AAA:

  • The National Safety Council reports that cell phone use while driving leads to 1.6 million crashes each year.
  • Nearly 330,000 injuries occur each year from accidents caused by texting while driving.
  • 1 out of every 4 car accidents in the United States is caused by texting and driving.
  • Texting while driving is 6x more likely to cause an accident than driving drunk.
  • Texting while driving causes a 400% increase in time spent with eyes off the road.
  • Of all cell phone related tasks, texting is by far the most dangerous activity.
  • 94% of drivers support a ban on texting while driving.
  • 74% of drivers support a ban on hand-held cell phone use
  • 11 teens die every day as a result of texting while driving.
  • According to a AAA poll, 94% of teen drivers acknowledge the dangers of texting and driving, but 35% admitted to doing it anyway.
  • 21% of teen drivers involved in fatal accidents were distracted by their cell phones.

ThePassionatePharmacist is not political, but supports a complete ban on texting and e-mailing while driving, and supports the use of hands-free cell phone use for talking.

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I have no statistics on cell phone use while near water, but please, please, please do NOT use your cell phone while bathing if your phone is plugged into a wall charger.  The results could be fatal.  A previous post on this blog (“Put Your Hand in the Hand”) has already mentioned the potential for cell-phones to harbor dangerous pathogens and to pass diseases from person to person.

Can a device so evil as a cell phone have any benefits attached to its use?  Certainly.  The phones can provide instant communication when emergency services may be needed.  They can transmit GPS coordinates when someone needs to be located.

Cell phones give you immediate access to information you otherwise might not have had for days, or longer.  You can get facts on diseases, weather information, natural disaster alerts.  You can find out how healthy you are by connecting with your doctor’s office.  You can know how healthy you should be, with advice, from hundreds of thousands of web sites.  You can download and use applications (apps) to track your health and fitness.  You can locate and adjust a suitable diet.  You can monitor your heat rate and blood pressure.  So many apps are available to help us improve the quality of our lives.  You can monitor your children, your parents, and your home.  You can turn your light on and off.  You can protect your home.  I’m sure there are many more advantages to cell phone use.

Advanced technology has always been a double-edged sword.  With scientific and technological advances come new challenges.  The use of cell phones has certainly improved many aspects of the human condition.  It has also given us other ways to harm ourselves and others.  Our challenge is to use it wisely.   It’s our call.

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