It used to be that we’d get all our kids settled back to school and then enjoy a bit of a pause before the other shoe fell with the inevitable concern over another flu season. With Swine Flu, Influenza H1N1 not taking a summer vacation and showing no signs of letting up, we didn’t have that luxury this year.
I went onto My Fox Boston this morning and talked with Keba Arnold about this very unique flu season with 2 influenza strains traveling among us and offered some practical tips to not only prevent the flu but be ready should it impact your town’s schools:
Don’t try and absorb everything at once. Focus on prevention today and I’ll help keep you informed as we learn more about the flu shots your family will need, when they will be available, and any breaking CDC alerts that are important for your family’s well being during the flu season.
*This blog post was originally published at Dr. Gwenn Is In*
When you were last enraptured by my physical exam series, I was explaining the different directions doctors use to confuse themselves and everyone else. I am happy to leave that land of relativity and now re-embark on the actual human body. I am sure this relativistic view of direction was invented by some liberal anatomist intent on socializing the human body. It is a stop on the road to death panels, in my opinion.
It’s good to get that posterior to me.
My distraction (I get distracted, you know) happened as I was trying to explain how the shoulder works. Since the shoulder moves in so many directions and with such huge angles, I felt it was necessary to totally confuse you and so hide any chance you would pick up my ignorance. It’s always good to keep your readers snowed. So, after spending a whole post making poems about the shoulder (that will no doubt go down in the anals annals of poetry about joints) and another post about the confusing directions we doctors use to confuse other doctors, I will now talk about the actual exam of the shoulder.
As you probably have been taught, the shoulder is the joint that attaches your arms to your body. Some people refer to the top of their torso as their shoulders (as in “shoulder straps”), but this is not what I am talking about. The shoulder is supposed to be the joint between three bones:
The humerus – which is the long bone in the upper arm, and got its name because of its habit of playing practical jokes on the ulna. The other bones are always inviting the humerus to parties.
The clavicle – also known as the collarbone. This bone actually looks nothing like a collar, and it resents the implication.
The scapula – called the shoulder blade. The collarbone is jealous because the scapula has a much cooler nickname. This causes the scapula to snicker often at the clavicle’s wimpy nickname.
The Wilderness Medical Society held its Annual Meeting in Snowmass, Colorado from July 24-29, 2009. The meeting was very well attended and once again demonstrated that the Society is the hub organization devoted to advancing the science and clinical practice of wilderness medicine. The format this year was to add a great number of presentations suggested by, and in many cases, delivered by members. In this and subsequent posts, I will present some of the wisdom offered in these presentations. For each post, I will put up a photograph I took while hiking in the Maroon Bells Scenic Wilderness Area.
Wayne Askew, Ph.D. and his colleagues taught on the topic of planning and preparing food for wilderness expeditions. Their goals were to allow the participants to develop an appreciation for the role that food and food planning plays in successful and enjoyable backcountry recreation; understand the similarities and differences between small and large group food planning; estimate energy and other nutrient requirements for individuals and groups; review guidelines for planning nutritional support for backcountry expeditions and recreation; and observe demonstration of recipes and preparation techniques for some useful backcountry food items.
A number of terrific observations were made. In no particular order:
1. Food planning is very important in outdoor activities, with emphasis on the word “planning.” One can enhance backcountry travel and survival with good nutrition.
2. Food planning is also important for morale. If people are hungry, malnourished, or unsatisfied, they are not “happy campers.”
3. The food planner for a trip or expedition should be chosen carefully, and should take care to take into account the dietary preferences of the participants.
4. Energy requirements for specific activities related to physical performance and caloric expenditure can be calculated and taken into account for food and meals planning.
5. There are sometimes foods for special needs (e.g., such as allergies, deficiencies, diseases, etc.). While many of the participants can handle their own needs, whomever is managing food should be aware.
6. There are persons who specialize in wilderness nutrition planning. They advise expedition planners on food, water and logistics; plan menu and food supplies for backpackers, wilderness tour groups and expeditions; assist in search and rescue operations; consult with food companies specializing in backpacking foods; and cook food.
7. If a person wants to accomplish nutrition planning, he or she should have a basic knowledge of human nutrition, understand human physiology and the role of food nutrients in extreme environments, know how to utilize food item selections to provide recommended nutrient intakes, and be a good cook in the outdoors.
Food planning by definition means thinking about food in advance. Dr. Askew and his colleagues recommended answering the following questions:
How much room is in your pack?
How much weight can you carry?
How long will you be traveling?
Where are you going?
How much fuel will you need and will you have access to water?
With whom will you be traveling?
Factors that affect food choices in the backcountry are food preferences; weight, perishability, taste and texture of foods; space in the pack; duration of trip; availability of water and fuel for food preparation; environmental conditions; experience with food preparation; special dietary needs; and personal beliefs.
This was a terrific educational experience, with terrific information such as this Planning Guide Nutritional Standards for Backpacking Food for One Person for One Day, based upon U.S. Army AR 40-25 Nutritional Standards for Operational Rations:
Energy (kcal) 3600 (will vary depending upon activity level)
Protein (g) 100
Carbohydrate (g) 440
Fat (g) 160
Vitamin A (RE) 1000
Vitamin C (mg) 60
Vitamin E (mg) 10
Calcium (mg) 800
Iron (mg) 18
Sodium (mg) 5000-7000
Fiber (g) 20-35
Finally, consider the following recipe for energy bars. This is one way to prepare less expensive and more nutritious (than store-bought) bars for personal use. As recommended by Askew and colleagues, you can be creative with this recipe, and use a variety of fruit, nuts, and grains. It is sufficient to make approximately 20 small bars.
Preheat oven to 350°
½ cup brown sugar
1 egg
¼ cup peanut butter
2 tsp vanilla extract
½ cup apple juice (unsweetened)
1 cup whole wheat flour
1 cup quick cooking oats
½ cup wheat germ
½ tsp baking powder
½ tsp baking soda
¼ tsp salt
½ tsp ground cinnamon
½ cup dried fruit (raisins, apricots, dried cranberries, etc.)
½ cup chopped nuts (walnuts, almonds, peanuts, etc.)
½ cup semi-sweet or dark chocolate chips
Mix dry ingredients in one bowl, wet ingredients and added “goodies”
(chocolate chips, raisins, nuts, etc.) in another, then combine. Spread the batter over a lightly greased cookie sheet about ½ -¾ inch thick. Use a spoon dipped in hot water to press the batter into the sheet and shape to the proper thickness. Bake for 10-15 minutes. Allow the pan to cool completely before cutting into bars. The bars can be refrigerated or frozen for longer shelf life.
Nutrition Information: calories 140, protein 5 grams, carbohydrates 20 grams, fiber 2 grams, fat 6 grams (saturated 1 gram) (% of calories from carbohydrates = 52%)
As I mentioned in my post last week, Journey of a Pinata Master, The lessons of a piñata party are many and subtle, where children must acquire sufficient skill and insight to reach the highest status. Let me show you how the custom of the Mexican piñata, stuffed with candy and used to placate children, has been adopted unwittingly by the U.S. healthcare system to create the Annual American Healthcare Bash. At this gala, candy replaces money and adults represented by special interest groups fill in for children.
The American Healthcare Bash is hosted yearly by insurance companies and the government. These two organizers start asking for donations. In 2009, the piñata will be stuffed with $2.4 trillion (give or take a few billion). In 1999, the piñata held a measly $1.2 trillion. By 2019, piñata is expected to hold $4 trillion. Party planners already are worried about finding a rope strong enough to hold this massive elephant piñata (or donkey, depending on which animal you prefer to hit).
Donations arrive through taxpayers, employers and anyone willing to gain admission to the festivities. Before the party starts, insurance companies remove 20% of the money as their “set-up fee” for hosting and establish the basic game rules. During the event, they take turns controlling the rope holding the piñata.
Any American who contributed to the party, including everyone over 65, is invited to watch the spectacle as the myriad special interest groups (SIGs) take turns batting the piñata. These SIGs include ad almost infinitum: primary care doctors, nurse practitioners, radiologists, imaging specialists, laboratory services, pharmaceutical companies, durable medical suppliers, lawyers, software engineers for electronic medical records, coders, billers, patient navigators, receptionists, schedulers, nurses, billing specialists, hospital administrators, HIPPA compliance “police,” pay-for-performance analysts, the American Medical Association delegates, and hundreds of other professional organizations and credentialing specialists.
Every year, more SIGs have been invited to the gala for their turn to bash the piñata. Most thank the public for such an extravagant event, repeating the chorus, “Don’t worry what this is costing, we’re not hurting you, we’re going after the piñata.” This piñata promises more loot than any other in America.
One by one, players are blindfolded and spun in dizzying circles by the insurance companies or government. Patients start the play and then hand we doctors the bat saying, “Good luck! Give your best shot at whacking what you can from that piñata! I could care less because I’m “protected” by my insurance plan.”
Each player swings wildly, sometimes accidentally bashing the others crowding around the bobbing target. The crowd roars its approval while some SIGs scream instructions of where to aim as the batter swings away. The rope jerking increases as more skilled batters take their turn. When money pours from the breaking hull of the piñata, hordes of SIGs dive in a feeding frenzy. After decades of careful construction, the piñata has been compartmentalized so that no single player can knock out too much money at once.
As the party winds down, most SIGs have received a “fair “ amount of money, but they are angry, never satisfied with their share. Of course, there are a few masters in the crowd, who are grinning ear-to-ear. When the party closes, the insurance companies take the piñata to another room and remove, behind closed doors, the remaining money (profit) of the day.
After counting its loot, the insurance companies emerge, announcing that it’s been another successful party, drinks all around! Then they say, “The party next year will cost only 8% more. Before you leave tonight, pay up.” Feeling threatened, taxpayers and employers reach deep into their pockets to pay for next year’s gala. Why ruin a great American tradition? If you get sick or don’t pay “your fair dues,” then hasta la vista.
As we grow up, most of us move past the need to gorge candy. Contrarily, when it comes to healthcare, few can limit how much they want to consume, nor recognize its often empty promises. Americans watch with fascinated horror at what’s happening in healthcare while remaining paralyzed to move cohesively towards change.
No matter how well intended and dedicated the doctors and nurses or how amazing the technology and medical breakthroughs to which the “insured” have access, the unrelenting piñata party lure inevitably results in a mass psychology of “How much money can I make?”
If you, dear reader, are scared of change and continue to support the current American healthcare piñata party, then be prepared to be beaten to a pulp. Now that you’ve paid your $20 co-pay entrance fee to the party and have emptied your wallet to the insurance company for what you believe is unlimited access to care, you have unwittingly turned yourself into the piñata.
Personally, after lots of experience and practice, I developed a healthy cynicism regarding the greed of this kind of parties. Ten years ago, I no longer could support the American Healthcare Bash. We built a new practice where the only focus is the patient; the patient pays transparently for the time they need. This idea delivers better care, 24/7 immediate access whenever and wherever you need help at a price that is almost 50% less than the current model. We need a lot more healthcare professionals and patients to invest in a new future of responsibility. A growing mantra is needed among patients and doctors alike, ”Do the right thing, for the right reason at the right price.” Unlimited wealth, and unlimited health are nothing but mirages, the deepest secret of all stuffed inside the piñata.
“We already have two girls at home and we want a son. We have too many girls.” My eyes welled with tears as I thought of the fate of this poor, helpless baby who had no voice, no rights, and who was about to be “attacked just because she was female.”
I pulled the ultrasound image from the chart and my heart quickened. The image was of the perfect outline of the precious little baby girl sucking her thumb. The timing of the ultrasound image was perfect.
I proudly showed them the image, and the look and emotion on their faces changed.
“That is our baby?” they inquired. “We didn’t think it had that much form, and she is sucking her thumb already?”
It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…
I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…
I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…
When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…
I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…
