September 10th, 2007 by Dr. Val Jones in Health Tips
6 Comments »
A colleague slammed his thumb in a door recently and got a black and blue nail. He told me that he searched for how to treat it on the Internet, and was advised to stick holes in the nail to relieve the pressure. I gazed at his thumb nail, peppered with tiny little needle divots and cringed as I imagined bacteria being introduced into the soft fleshy part under his thumb nail. His thumb otherwise looked good – no mallet finger, no swelling – no blood under pressure that I could see.
I decided to do a little research on this issue, since all I’d ever done for a black and blue finger nail before is let nature take its course – it’s painful for a few days, the nail eventually falls off, and a new one grows.
However, in many cases creating a hole in the nail to let the blood escape can significantly relieve pain in the acute phase. Making the hole is tricky – it has to be large enough to let the blood out, and it has to be done with a sterile instrument so that bacteria are not introduced below the nail. Most physicians recommend a local anesthetic to ease the pain prior to making the hole. The hole can be made with a large bore needle (but you have to be careful not to place the needle in too deep) after swabbing with alcohol, or by burning through the nail with the tip of a paperclip that has been heated with a butane lighter. Creating the nail hole (known as trephination) is best done by a medical professional.
Routine antibiotic coverage is unnecessary. If the nail is loose, split, or a cut extends past the edge of the nail, the nail should be removed,
the cut closed with stitches, and the nail reapplied as a
dressing. It’s also important to make sure that the thumb bone is not fractured.
Bottom line: black and blue nails (subungual hematomas) are very painful and may be relieved by having a medical professional place a hole in the nail. But don’t try this at home, folks.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 10th, 2007 by Dr. Val Jones in True Stories
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I was having lunch in a DC garden hideaway with some colleagues from Revolution Health when the subject of 9/11 came up. We all agreed that it was one of those events that everyone remembers vividly, no matter where they were in the world at the time. Each of us took turns telling the others where we were and what we were doing on that fateful day. Each person’s account was moving and personal. My story follows… [insert fuzzy dream sequence graphics here]
I was getting off a night shift rotation at a hospital in lower Manhattan, sitting in morning report – my eye lids sticking to dry corneas, my head feeling vaguely gummy, thoughts cluttered with worries about
whether or not the incoming shift of residents would remember to perform all the tasks I’d listed for them at sign out.
And as I dozed off, suddenly our chief resident marched up to the front of the room, brushing aside the trembling intern who was presenting a case at the podium at the front of the dingy room. “How rude of him” I thought hazily, as I shifted in my seat to hear what he had to say.
“Guys, there’s been a big accident. An airplane just crashed into the World Trade Center.”
Of all the things he could have said, that was the last thing I was expecting. I shook my head, wondering if I was awake or asleep.
“We don’t know how many casualties to expect, but it could be hundreds. You need to get ready, and ALL of you report back to the ER in 30 minutes.”
I thought to myself, “surely some misguided small aircraft pilot fell asleep at the controls, and this is just an exaggeration.” But worried and exhausted, I went back to my hospital-subsidized studio apartment and turned on the TV as I searched for a fresh pair of scrubs. All the channels were showing the north tower on
fire, and as I was listening to the news commentary and watching the flames, whammo, the second plane hit the south tower. I stared in disbelief as the “accident” turned into something intentional. I remembered having dinner at Windows on the World the week before. I knew what it must have looked like inside the buildings.
I was in shock as I hurried back to the hospital, trying to think of where we kept all our supplies, what sort of injuries I’d be seeing, if there was anything I could stuff in my pockets that could help…
I joined a gathering crowd of white coats at the hospital entrance. There was a nervous energy, without a particular plan. We thought maybe that ambulances filled with casualties were going to show up any second.
The chief told me, “Get everybody you can out of the hospital – anyone who’s well enough for discharge home needs to leave. Go prepare beds for the incoming.”
So I went back to my floor, recalling the patients who were lingering mostly because of social dispo issues, and I quickly explained the situation – that we needed their beds and that I was sorry but they had to leave. They were actually very understanding, made calls to friends and family, and packed their bags to go.
And hours passed without a single ambulance turning up with injuries. I could smell burning plastic in the air, and a cloud of soot was hanging over the buildings to the south of us. We eventually left the ER and sat down in the chairs surrounding a TV in the room where we had gathered for morning report. We watched the plane hit the Pentagon, the crash in Pennsylvania… I thought it was the beginning of World War 3.
The silence on the streets of New York was deafening. Huddling inside buildings, people were calling one another via cell phone to see if they were ok. My friend Cindy called me to say that she had received a call from her close friend who was working as a manager at Windows on the World. There was a big executive brunch scheduled that morning. Cindy used to be a manager there too… the woman’s last words were, “the ceiling has just collapsed, what’s the emergency evacuation route? I can’t see in here… please help…”
That night as I reported for my shift in the cardiac ICU, I was informed by the nursing staff that there were no patients to care for, the few that were there yesterday were either discharged or moved to the MICU. They were shutting down the CICU for the night. I wasn’t sure what to do… so I went back to my apartment and baked chocolate chip cookies and brought in a warm, gooey plate of them for the nurses. We ate them together quietly considering the craziness of our circumstance.
“Dr. Jones, you look like crap” one of them said to me affectionately. “Why don’t you go home and get some rest. We’ll page you if there’s an admission.”
So I went home, crawled into my bed with scrubs on, and slept through the entire night without a page. The disaster had only 2 outcomes – people were either dead, or alive and unharmed – with almost nothing in between. All we docs could do was mourn… or bake cookies.
What were you doing on 9/11? Join our forum to share your stories.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 7th, 2007 by Dr. Val Jones in Health Tips
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Is it safe to eat microwave popcorn? In case you missed it, a surprising new case of diacetyl lung damage
(so-called popcorn lung) was discovered in a patient who is a popcorn fanatic.
He reported eating 2 bags of artificial butter flavored popcorn per day
for years on end and began to notice shortness of breath.
My bottom line: avoid diacetyl, don’t avoid popcorn. Popcorn itself is
not harmful or dangerous (unless you’re under age 5 and are at risk of
choking or inhaling it) – just make sure it’s not laced with chemicals.
Five years ago the New England Journal of Medicine published a study linking a popcorn chemical (diacetyl) to a serious lung condition in 8 popcorn factory workers.
The lung condition, also known as bronchiolitis obliterans, is an
inflammatory reaction to diacetyl that can reduce lung capacity by as
much as 80%. Certain people who inhale too much of the chemical form
scar tissue as a reaction, making the lungs stiff and causing cough and
shortness of breath.
In this week’s case, the astute pulmonologist examining the popcorn addict remembered the 2002 NEJM article, and thought to ask him about popcorn exposure as part of her work up for his breathing complaints. As it turns out, his exposure to popcorn chemicals is the likely cause of his lung damage. Sadly, though, once the scarring occurs there is no way to return the lungs to their original state of heath. The only known treatment for popcorn lung is a lung transplant.
There has been incredible interest in this story because microwave popcorn is a part of most of our lives. The United States is the single largest consumer of popcorn worldwide, and we purchase over 1 billion pounds of unpopped corn per year. We naturally wonder: could this happen to me? Am I (or my kids) at risk?
First of all, I think that diacetyl should be avoided by all consumers of popcorn. ConAgra, the parent company for Orville Redenbacher and Act II, has agreed to immediately remove this chemical from its artificial butter flavored popcorn. Nonetheless, we should scrutinize the labels of any popcorn that we intend to purchase to make sure that it doesn’t contain diacetyl.
Second, the good news is that not everyone’s body forms scar tissue in reaction to this chemical. In the same way that we’re not all allergic to the same environmental agents, our bodies are not all going to respond to diacetyl by developing lung scarring. That said, why tempt fate by inhaling fumes that have harmed a small number of people?
Third, it does seem that it requires prolonged and high exposure to diacetyl to be at risk for popcorn lung. So if you’re not a buttered popcorn maniac (consuming several bags per day for years on end) your risk is extremely small, even if in the past you’ve eaten the occasional microwave popcorn containing the chemical.
If you are looking for alternative healthy snack options check out this link.
Hope this post allows some of you to breathe easier!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 7th, 2007 by Dr. Val Jones in Expert Interviews
2 Comments »
Two new studies reported increasing suicide rates in teenagers. The first noted a trend between decreased use of anti-depressant medications (SSRIs) in teens and an increase in suicide, the second reported an increase in female teen suicide in particular.
What could be causing these tragic increases? I interviewed Revolution Health psychologist, Dr. Mark Smaller and child psychiatrist, Dr. Andrew Gerber, to get their take on this disturbing trend.
1. In previous research,
increased suicidality was associated with SSRI use in teens. Now this study
suggests that lower SSRI use is associated with increased suicidality. How do
you explain this?
Dr. Smaller: Following the previous research, parents and some physicians cut back on SSRI use for depressed teens. However, in doing so they may have neglected those teenagers who could have benefitted from an antidepressant. The problem with these medications is that they effect so many parts of the brain that it’s difficult to predict how different patients will respond to them. Also, these medications are often prescribed in too high a dosage. What needs to happen is that the patient, teen, child, or adult must have a full psychosocial evaluation that takes into account the whole person, and the environment in which he or she is living. A clear treatment plan combining talking therapy (individual or family) and perhaps medication must be implemented. This is not being done in enough instances. With a proper evaluation and a carefully designed treatment plan (as well as close monitoring of the teen) therapy may be further customized to the individual.
Dr. Gerber: The possibility of an association between suicidality and SSRI use in children
and adolescents is of clear concern to many people, including all psychiatrists
and parents of children on medication. Despite all the accumulated research to
date, it is still very unclear how this association works. However, we do know a
few important things.
First, in all the studies of SSRI use in children, there
is no report of a completed suicide attempt in a child who was taking an SSRI.
This goes to show that completed suicides in children, while tragedies whenever
they do happen, are rare events and therefore very hard to study methodically.
Second, in those studies that have shown a possible association of suicidal
thoughts (though not actual suicides) with SSRIs, there is a lot of disagreement
and controversy over how to best measure these thoughts in an accurate way. How
one does this influences the results considerably.
Third, it is important to
keep in mind all the ways in which an association between SSRIs and suicidal
thoughts may appear to exist because of how the data are collected, even if SSRIs
really don’t bring about suicidality at all. For example, it’s certainly true
that doctors are most likely to give medications to the kids who are the most
depressed and the kids who are the most depressed are most likely to be
suicidal. So it might look like SSRIs are related to suicidality, when they are
really being used to treat those kids who are most likely to develop it.
The
best way to really tease these apart is to randomly assign enough children
either to SSRIs or non-SSRI treatment and then observe what the differences are.
The problem, is that (1) the data are so good that SSRIs help many kids with
depression that it would be unethical to withhold treatment from half the
children in order to complete such a study, and (2) suicidality is rare enough
that this study would have to be enormous, and thus is impossible to
do.
With all this said, it is not surprising at all that an overall
decrease in the use of SSRIs, most likely due to the greater caution that
clinicians now have in using these medications in children, would lead to more
suicidality on a broader scale. We know that SSRIs help most children who take
them and this is undoubtedly a more powerful effect than any extent to which
SSRIs cause suicidality (if this is true at all).
2. Is there a role for
SSRIs in teens?
Dr. Smaller: I think so but only after a full diagnostic evaluation is made by a skilled mental health professional who works with teens, family and is familiar with the developmental phase of adolescence.
Dr. Gerber: There is unquestionably still a role for SSRIs in teens as long as they are
monitored carefully by a well trained clinician who, following agreed upon
guidelines, has decided that an SSRI is the right treatment for this teen. Of
course, as always, other treatments and their advantages and disadvantages
should be considered too. But for the best interests of kids and teens, SSRIs
need to remain a possibility.
3. What would you counsel
parents about these drugs?
Dr. Smaller: Get a full physchological evaluation and treatment plan so that you can make an informed decision about what might help. The mental health professional and the parent must have a working alliance to insure that the treatment is successful.
Dr. Gerber: I would advise parents that it is always good for them to be well informed and
vigilant about the risks and benefits of all treatment that they consider for
their children. There is much that we do not know about child psychiatric
illness and we are working furiously to learn more. In the meantime, though we
have to be careful to keep an open mind to both sides and to not make premature
judgments either in favor or against any one treatment. SSRIs have shown
themselves to be useful with many children and, in the hands of a well trained
professional, can continue to be very helpful to the right children and their
families.
4. What do you make of
the suicide rate increase in girls? What could be behind
this?
Dr. Smaller: This is alarming. The onset of adolescence for girls and boys is a hugely disruptive developmental phase, and maybe more so for girls with the onset of puberty. The teen years can be fraught with family issues that exacerbate moods and create symptoms. Our culture puts huge demands on all of our adolescents and this research might be showing that it is taking a high toll on girls. Social roles, peer pressure and issues, academic demands and family strife all contribute. The high incidence of eating disorders among teenage girls is a clear example of a symptom to which many teenage girls are vulnerable.
Dr. Gerber: The greater increase in suicide rates among teenage girls is surprising and
experts are unsure of how to interpret this. Since the overall number of
suicides is small – 94 in 2003 and 56 in 2004 – it is hard to interpret what was
different in this group of teenage girls. There are so many increasing pressures
on teenage girls today – from issues around body image and weight to balancing
complicated societal expectations, what some experts term pressure to live up to
a “superwoman ideal” – that one might speculate it is leading more and more
teenage girls to feel overwhelmed and hopeless. However, what we really need, as
with the SSRI controversy, is more carefully collected data and thoughtful
discussions between families, patients, and clinicians, to understand what is
happening and how we can prevent it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 5th, 2007 by Dr. Val Jones in News
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Like most of us, this headline made me squirm – visions of the Minotaur, mermaids, and Dolly the sheep with a human face, danced in my head. But as much as this form of experimentation seemed ethically wrong, I decided to figure out what exactly they were proposing.
The Human Fertilisation and Embryology Authority (HFEA) ruled that British scientists could now use animal eggs to host human stem cells. Because there is a shortage of human eggs to use for experimentation, they asked that rabbit or cow eggs be used.
Stem cells are the first kind of cells created when an egg is fertilized and divides. They are capable of developing into any kind of human cell – and are therefore quite interesting in terms of their potential to heal. (Transplanting these cells into damaged tissue can actually repair the tissue to some extent – no matter if its brain, heart muscle or other tissue). But these stem cells have to incubate inside an egg (kind of like a tiny soft shell) if they are to divide.
So the scientists are asking to use animal egg shells (without the nucleus that contains the majority of their DNA) as mini incubators for human stem cells. The HFEA approved that use – but has NOT approved mixing human and animal DNA in a human egg. Such a blend would serve no useful scientific purpose.
Ultimately, the goal of this human-animal embryo experiment is to allow for the creation of many more human stem cells without harvesting human eggs to do so. It also may help scientists to understand what these egg “shells” do to influence the growth of stem cells – if we knew how that worked, we may not need to use human eggs to retrieve stem cells, but could create them from any cell in the body.
So, although this embryo experiment sounds alarming at first – it’s actually a way to do stem cell research without using so many human eggs. Now, that doesn’t mean that I necessarily condone the idea – but it helps put into perspective what the scientists are proposing. Rest assured that there will be no Minotaurs resulting from these particular experiments.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
