April 13th, 2008 by Dr. Val Jones in True Stories
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I received a panicked call from my younger sister today. She is the mother of one-year-old identical twin girls, born slightly prematurely. During her pregnancy she had a problem with twin-twin transfusion syndrome and had to lie on one side for many weeks to ensure that both girls received an adequate blood supply. She delivered by Cesarean section and fortunately both girls have been doing well. That is, until a few hours ago.
My sister described an episode in which her daughter was in the bathtub and suddenly had one of her pupils become very large. It remained dilated for several minutes, which caused her to call her husband in to take a look. He confirmed that the eye was dilated and they decided to call me right away because they’d heard that a dilated pupil might have something to do with concussions or head injuries, though the little girl had not had any recent trauma to her head.
I tried to get a full history from them – they said she was acting “totally normally” – the usual peeing, pooping, eating checks were fine. They said she was sleeping well, not vomiting or lethargic, and that her pupil had now (after several minutes) returned to normal size. They said her fontanel was not bulging, and when I asked them to shine a light in her eyes they both constricted immediately.
My sister asked me, “what could this be?”
Ugh. I’m not a pediatrician, nor an ophthalmologist, but I do know that asymmetric pupils are usually an ominous sign. All I could think of was “space occupying lesion” but I didn’t want to scare my sister unnecessarily. All the other history sounded so reassuring (the child was well, with no apparent behavior changes, the eye had returned to normal, etc.) that I had to say that they should get in touch with the pediatrician on-call.
And here’s where things got confusing. My mother called me by coincidence just after I hung up the phone with my sister. She had been visiting with the babies for a full week, and slept next to their cribs during their vacation. I told my mom about the pupil issue, and she started relaying some potential “symptoms” that she had witnessed over the past week or so. She claimed that the baby had indeed vomited recently, that her behavior was different than her twin (more irritable and emotionally labile) and that her sleep patterns were also disrupted.
Now I was more concerned – was this early hydrocephalus or maybe even brain cancer? Would I be responsible for missing a diagnosis? I was thousands of miles away from the infants and trying to piece together a story from historians with different observations. So I called some pediatrician friends of mine and asked what they made of this. One said – “anisocoria is a concerning symptom in an infant, she needs a CT or MRI to rule out a tumor pressing on her eye nerve. She should go to the ER immediately.” The other said that since there were no other current symptoms, and the eye was back to normal, it should be worked up by an ophthalmologist as an outpatient.
What a bind to be in – I have some witnesses describing very concerning symptoms, others suggesting that everything’s fine except for a fleeting period of pupil size mis-match. I have dear friends suggesting everything from an immediate ER visit with sedation of the child and a head CT or MRI to watchful waiting and distant outpatient follow up. And I have my sister relying on my judgment (as a non-pediatrician) to tell her what to do.
Here’s what I did – I got my sister and her husband on the phone and explained to them that I take their observation of pupillary dilatation very seriously. I explained that this is not a normal event, and should be followed up by an expert to make sure that there’s no underlying cause of the eye symptoms. I also said that the fact that the baby is acting normally and the eye is no longer dilated are reassuring observations. I told them that they should keep a close eye on the infant, and that if they see any hint of recurrence of the pupil problem, or anything out of the ordinary like vomiting, inconsolability, lethargy, swollen fontanel, fever, or strange body movements or seizures, they should go to the ER immediately. In the meantime they should alert the doctor on-call to the situation and discuss everything with their pediatrician during her next available office hours.
I hope that was the right approach. I will not rest easily until the baby has been fully examined by an expert. Being a doctor carries with it a lot of anxiety and personal responsibility – at any time of the day or night your peace of mind can be uprooted by an abnormal finding relayed to you by friend, family, or patient. And if anything goes wrong – or if interventions are not achieved at an optimal speed and accuracy, this question will forever plague you: “Should I have done something differently?”
Who knew that my relaxing Sunday afternoon would be turned upside down by a dilated pupil?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 28th, 2008 by Dr. Val Jones in Expert Interviews
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Tanning salons are a $2 billion dollar industry in the U.S., and their bottom line has been damaged by the medical community’s warnings about the link between UV (ultraviolet) exposure and skin cancer. Recent studies have found that some Americans may have too little Vitamin D in their diets, and since the body can synthesize this vitamin when exposed to sunlight, the tanning industry is campaigning for the potential health benefits of UV exposure. Vitamin D helps to keep bones strong, and may provide protection from osteoporosis, hypertension, cancer, and several autoimmune diseases.
Now, in the interest of full disclosure – I did use tanning salons in my late teens and early 20’s. I knew it could be harmful, but (like a moth to a flame?) couldn’t resist the sweet lure of changing my “glow in the dark” skin to a light shade of cream (no melanin is no melanin, friends). So, I was more than curious to get an insider perspective on the tanning industry vs. medical professionals battle. I turned to a dermatologist whom I respect immensely: Revolution Health expert, Dr. Stephen Stone. I asked him the following questions:
1. Does exposure to ultraviolet light have health benefits?
Other than for treatment of disease (psoriasis for one, atopic eczema, cutaneous T-cell lymphoma, for example), the only known benefit is the production of Vitamin D in the skin – and adequate vitamin D can be obtained from food and supplements without the danger of UV exposure – and even in the worst climates, the sun is an adequate source of Vitamin D without resorting to tanning beds.
2. What amount of sun exposure is currently recommended?
There is no “recommended daily allowance” for sun exposure, and 15 – 20 min a day of unprotected sun on the arms (not total body) will allow peak production of vitamin D.
3. Are there alternatives for good health?
UV is not needed at all for “good health.”
4. What evidence is there that exposure to tanning beds increases the risk of skin cancers?
The US dept of HHS and FDA officially classify UV as a “known carcinogen” and there are numerous articles supporting this: Gandini et al., Meta-analysis of risk factors for cutaneous melanoma, European Journal of Cancer, Westerdahl et al., Risk of cutaneous malignant melanoma in relation to use of sunbeds, British Journal of Cancer (2000), Karagas et al., Use of tanning devices and risk of basal and squamous cell cancers, Journal of the NCI (2002).
5. How would you describe that risk?
Significant.
6. What do you think of the recent ad campaign sponsored by the tanning industry?
Same as I think of cigarette ads!
7. What is your take-home message to patients about tanning salons?
If the cancer doesn’t get you, think of the wrinkles! We focus on cancer, because that’s life and death, but no one can deny that the UV causes premature aging and wrinkles.
So there you have it, folks. Indoor and outdoor tanning are both harmful to your skin. Whether or not you get cancer, wrinkles are a sure result of excessive exposure to UV radiation (with a little help from our friend, gravity). So I’m going to keep up with my sunscreen (see Dr. Benabio’s blog post), get a skin check annually, and accept myself as the tanless wonder that I am. Or maybe I should create a pale people support group? Any joiners?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 21st, 2008 by Dr. Val Jones in Uncategorized
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This week I was honored to be featured as the first post in the line up at Polite Dissent’s Grand Rounds. Over the past couple of weeks Revolution Health’s bloggers have been doing their part to contribute to health knowledge. Here’s my round up of the best of their recent posts:
Health tips
Spring break is coming up for millions of children and teens. Dr. Stacy Stryer has some health tips for sun and water safety.
Stretching is an important healing technique for some injuries and conditions. Dr. Jim Herndon explains what we know about the use and value of stretching exercises.
Does an affair mean your marriage is over? Mira Kirshenbaum has some suggestions for healing after infidelity, and a group to help you do it.
Some people feel regret after prostate cancer surgery. Dr. David Penson offers some empathy and advice.
What’s new in prostate cancer treatment? Dr. Mike Glode give a short synopsis.
Meditation might decrease your sleep requirements. Dr. Steve Poceta reviews this claim.
Did you know?
Men hate to apologize. Relationship expert Mira Kirshenbaum has some ideas as to why that might be.
Teen scientists are contributing to colon cancer research. Dr. Heinz-Josef Lenz discusses what his daughter and a Junior Nobel Science Award-winning teen have in common.
Toenail fungus is very common in the elderly. Dr. Joe Scherger explains why this is so, and why it’s so difficult to treat.
Overweight menopausal women may suffer more severe hot flashes. Dr. Vivian Dickerson explains why.
An anti-snoring shirt has been developed to help people remain on their sides while asleep. Dr. Steve Poceta explains how sleep position is related to snoring.
Human growth hormone doesn’t actually strengthen your muscles, it just makes you retain water. Dr. Jim Herndon reviews the latest research.
There’s a new clinical trial designed for women with metastatic colon cancer. Dr. Heinz-Josef Lenz explains what the scientists are hoping to learn from the research study.
Baby-naming is an art. Dr. Stacy Stryer discusses the history of finding just the right name for your child.
Patient advocate Robin Morris discusses her opinion of Larry King’s recent autism-focused show.
How should a doctor share bad news with a patient? Neurologist Larry Leavitt explains.
***
Happy Easter weekend everyone!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 13th, 2008 by Dr. Val Jones in Humor
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In case any of you aren’t familiar with The Onion, it’s a spoof newspaper whose articles range from hilarious to irreverent. Here are some recent health headlines that struck me as funny:
Depressed Cow Eats Entire Haystack
Nation’s Bachelors Demand Health Care Coverage For All Their Buddies
Pharmaceutical Company Says Its New Anti-Depressant Is ‘Worthless And Dumb’
Very Specific Food Pyramid Recommends Two To Three Shrimp Scampis Per Year
Disease-Free Water Tops List Of World’s Most Popular Beverages
Half Of 26-Year-Old’s Memories Nintendo-Related
Swanson Foods Launches Hungry Man Line Of Apparel
Area Man Thinks He Can Save Relationship With Pancakes
American Cancer Society Unveils 1.2-Megaton Anti-Cancer Missile
New Product Can Do All That, More
Barky Dog Just Going Bark, Bark, Bark
And for you scientists in the audience, here’s an Onion classic, mocking the medical peer review process. Enjoy!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 12th, 2008 by Dr. Val Jones in True Stories
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Every physician has a few traumatic patient stories forever etched in their minds. My friend Dr. Rob recently blogged about the sad case of a little boy with an ear infection – his bulging red eardrum suggested a common problem requiring antibiotics. Little did anyone know that the bacteria behind the drum would get into his spinal fluid, causing meningitis and rapid death. Another emergency medicine physician tells the story of an elderly woman whose aorta dissected right in front of the medical team, with barely enough time for the trauma surgeon to save her life.
One of my surprising moments occurred when I was an ER resident. A middle aged woman (we’ll call her Lizzy) was sent to the ER in the middle of the afternoon after a near-fainting episode in a pain management clinic. She was fairly well known to the more senior residents and staff (she was a chronic pain patient on multiple medications who came to the ER for frequent generalized pain work ups and rescue doses of her meds). So since this lady had cried wolf a few too many times, she was assigned to me – the newbie.
I had no pre-conceived notions about Lizzy, and hadn’t experienced her exaggerated and benign abdominal pain claims in the past. She was lucid, with a smoker’s cough and mildly disheveled, short hair with dark roots and blond tips. She explained that she had been at her usual pain management appointment when she got up from the waiting room chair to register and almost blacked out. She described feeling lightheaded, and needing to sit back down immediately. The clinic staff called our ER to transfer her for an evaluation.
Lizzy seemed fairly cheerful and unconcerned about her near fainting – as if swooning bought her a free ride to the ER to see her “other doctors.” But still, something didn’t seem right to me about her. She was light skinned, but not pink enough. Her blood pressure was low-normal. She had no particular pain anywhere, though on the levels of narcotics she was taking it would be a miracle if she could feel any pain at all. I decided to watch her, take serial vitals, and order a CBC and Chem 7 to see if there might be any signs of dehydration or anemia.
The second set of vitals showed a slightly lower blood pressure and a slightly higher pulse. She sat on the stretcher, watching the TV without any particular sense of urgency. Since it was an unusually slow afternoon, I got the chance to ask for more details of her medical history. Lizzy described her normal daily activities at the assisted living center, and how she had attended a party where she’d had a bit too much to drink and had fallen on a chair a couple of days ago. She said it hurt at first in her left upper quadrant, but it felt only slightly sore now.
Her CBC came back with a lowish hematocrit, and a third blood pressure reading was trending lower yet. I really wasn’t sure what was going on, but I was getting nervous. I presented the case to my attending (who knew the patient very well) and suggested that we get an abdominal CT to rule out internal bleeding.
He rolled his eyes and sneered at me. “Do you know how many CTs this woman has had already?”
“Um, no…” I winced.
“She gets one every freaking time she’s in here, and it’s always non-specific. Inexperienced residents like you are wasting hospital resources on drug seekers!”
“But she does have some anemia, low blood pressure, and a history of abdominal trauma…” I mumbled.
“She’s always slightly anemic, with low blood pressure – what would YOUR blood pressure be on high dose oxycontin?”
“But she looks pale and she almost fainted…” I tried to continue my argument.
“Alright, Jones… I’m going to let you order the CT as a learning experience for you. This is a teaching hospital, and I guess that means that we can irradiate patients at will. Go ahead… we’ll see what it shows.”
By this time I was really questioning myself. I’d gotten in an argument with one of our attendings who knew this patient intimately and had years of medical experience beyond my own. If I was wrong about her, he’d make me pay for the rest of the year – and tell all the other residents about my poor clinical judgment and wasted hospital resources. I was very nervous, but I just had to follow my instinct.
I sent the woman to the CT scanner with a reassuring pat on the shoulder. She winked at me and disappeared into the radiology suite.
Ten minutes later I was paged by the radiologist, his voice was tense – “Your patient has a splenic laceration, you’d better call in the trauma surgeons. She’s fading fast…”
Before I could put the phone down I heard the trauma team being paged overhead and some surgeons emerged from behind a curtain and started running to the CT scanner, almost knocking me off my feet in the hallway.
As it turns out, the trauma team was able to save Lizzy by removing her spleen. She spent several days in the hospital receiving blood transfusions and recovering from the operation. My attending never mentioned the incident again, though I never forgot Lizzy’s near-death experience. Maybe it was a blessing that I was a “newbie” when I met Lizzy – my lack of knowledge of her usual behavior allowed me to view her with a fresh eye, and take her complaints seriously. It’s really hard to hit that reset button with every “frequent flier” in the ER – but sometimes it can save a life.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
