That Just Goes to Show You: Time Flies

The Daily Apple™© Volume 3, Number 2
June 4, 2014

PGY 41, Day #331

That Just Goes to Show You ... There is Always Something and Time Flies

When I use that common phrase and especially when I add "There is Always Something", Gilda Radner and her character Roseanne Roseannadanna from Saturday Night Live come to mind.

http://en.wikipedia.org/wiki/Roseanne_Roseannadanna

Then, a smile comes over me and, given enough pause, a bit of out loud laughter erupts.  AKA LOL.  If you are over 40, you probably know of her and, if not, check her out.  Your heart and soul will be better for it.  Then on to serious business.  Yes, humor and laughter are useful healing tactics, but, eventually, we get back to action required.

My point?  As PGY #41 draws near to a close, I must apologize to my followers for the limited number of blogs posted here this year.  My excuses?  Patient Care, Teaching, Administration, Family Care and Veritas Health Care.  Yes, most of my "free time" has been spent working and writing for the nonprofit Veritas Health Care

http://www.veritashc.org.php53-9.dfw1-1.websitetestlink.com/

and the Veritas Health Care blog

http://www.veritashc.org/blog/

Please join us at Veritas Health Care.  We are the NONPROFIT Veritas Health Care and if you care about health care and want a platform and springboard to help Build Better Health and Health Care you might want to sign up.  We continue our efforts to Build Best Practices and to Optimize Quality and Performance Improvement through application of our available tools.  We are happy to show you how to use our tools to promote and optimize personal health, family health, community health and health care.  We are local and global.

Also, when time permits, I will add teaching points to both blogs.  This may create some overlap, but the spectrum of knowledge and skill required for optimal self care knows no boundaries.  In other words, I am willing and able to teach anyone who is motivated to learn.  So, with that in mind, please forward specific questions or comments on any Health and Health Care related subjects.

Thanks for caring.

Dr. Mike
Michael F. Mascia, MD, MPH

One More Thing on EMR Flaws, Dangers: Why Patients First?

The Daily Apple™© Volume 2, Number 9
August 29, 2013

Technology Failed Again.  That reminds me to remind you about the need for redundancy, when it comes to HIT stuff.

When thinking about EMR<>EHR<>HIT stuff and designing better HIT systems ... remember this.
Wall street went down on (Thursday, August 22, 2013)

  http://dealbook.nytimes.com/2013/08/22/nasdaq-market-halts-trading/?nl=todaysheadlines&emc=edit_th_20130823&_r=0

but, nothing happened.  A few guys made less money?  There was a delay in trading ... so what?  Who cares?  If I were one of those trader guys, I would have hiked out of the office, grabbed a cup of coffee, walked down to the river, felt the sunshine and watched the water run by.  "Call me when things are back up and running."  But, in my business, I can't do that.

There are few things in life during which time is critical.  In fact, time is usually irrelevant.  But, in the spectrum of life, health, healthcare and death, the natural history of injuries and diseases dictate some of the critical moments in life.  So, chill when you can ... drink the coffee and smell the roses.  And, recognize those things that require immediate attention ... true emergencies.

In other words, there are certain illnesses and injuries during which minutes ... even seconds of delay in proper diagnosis and definitive treatment may result in permanent cell damage, organ damage, loss of limb, or loss of life.  The diagnosis and treatment of these conditions is CRITICAL CARE ... That's my day job.  In this business, there is no excuse or time for "systems down".  In other words, we have to be ready to take care of these sorts of problems 24 x 7 with or without technology.  That is the simple truth.  Veritas!

During Katrina, ALL SYSTEMS WERE DOWN within a few hours and they stayed down for days to weeks.  In the immediate aftermath of Katrina, we had NO RECORDS on many patients, some of whom were critically ill.  Direct care Patient<>Physician<>Provider prevented many disasters in our hands.

Intermittently, every electronic record and system I have used has failed.

Intermittently, every piece of technology I have ever used has failed.

Conclusion:  There is no such thing as failsafe.  But, we can build redundancy into EMR<>EHR<>HIT Systems that will generate smart cards and "hard copy" intermittently, at a frequency to be dictated by the "situation" the patient happens to be in at the moment.  If "the patient" is in the hospital, or the Intensive Care Unit, hard copy of the EMR/flow sheet should be printed out at least every 8 - 12 hours. At the push of a button, the "system" should generate a smart card and paper summary for each patient.  In critical situations, attach that summary and smart card with all essential data, at least a problem list, to name tag that hangs on the patient's neck.  That way, the patients and the folks on the front lines with the patients who are responsible for their care will have a little something to help them get some background information.  And, the folks who receive them will also have something to go on.  Add this capacity to the design of any robust EMR<>EHR<>HIT System.  Just my opinion.

And, HIT guys ... don't look at me as if I have two heads when I tell you these things.  Fix it!

Dr. Mike
Michael F. Mascia, MD, MPH

The Daily Apple™©: Take The Best Care™© of Yourself

The Daily Apple™© Volume 2, Number 6

Friday, June 28, 2013

PGY #40  Day #363

Take The Best Care™© of Yourself

From Dr. Mike and Infinity Health Solutions

 

For our final blast of PGY 40 I take you back to The Stress Management Workbook.  In fact, I take you to the end of the book, page 162, which I have reproduced here.  There is ONE critical point to make with regard to altering your life and lifestyle to promote optimal health and well being.  It takes time to do it right.  

This is true for many reasons, not the least of which is this: we are programmed to behave in a certain way.  Not completely hard wired, humans have the capacity to change and to change themselves, but the biology of change involves reprogramming the brain and nervous system and that does take about two years.  This is about a mix of genetics and biology that amounts to "plasticity" of the nervous system.  If you eat well, sleep well, and get proper exercise, your body will enable the necessary changes in the nervous system that facilitate your ongoing path to health. I will not dwell on the science of this phenomenon now, but ask if you have questions about it.

The point is this: You can change.  Don't give up.  Take the time necessary to make the change stick.  If you screw up, fall down, make a mistake, go out of line, fall off the track ... get back on track ASAP.  The more time you spend on track, the easier it will be to stay there.  Do not give up ... do not surrender.

Below is the relevant page from The Stress Management Workbook.

Enjoy!

Dr. Mike

162 THE STRESS MANAGEMENT WORKBOOK

PITFALLS ON THE PATH TO HEALTH,

OR WHY CHANGE IS DIFFICULT

Change is not always easy to implement. There are several reasons

for this. You have been practicing your present style of thinking and

behaving for many years. Much of your behavior and attitude has

become habit. You will have trouble realizing you have engaged in

the habit until after the fact. 

Do not make your goal the immediate

and total elimination of the old behavior or the addition of new ones:

You will set yourself up for failure and add to your stress. A realistic

goal would be to reduce the frequency of the behavior(s) or increase

the frequency ofnew behaviors over time so that one or two years from

this date you can recognize substantial change. 

You can change habits

faster by  

(1) asking friends to tell you when you are engaged in the

old behavior; 

(2) deliberately engaging in the habit in an exaggerated

manner several times a day so that you become supersensitized to it;

and 

(3) keeping a log with you and writing down each time you or a

friend notice the habit-reward yourself for specified reductions in the

frequency of the behavior.

Often people will not change even if the present situation is not

satisfactory because the discomfort of the known is not as great as

their fear of the. consequences of unknown behavior. If you become

more assertive, for example, you will have to deal with the reactions

ofthose around you, some ofwhom may prefer that you stay meek and

docile. If you discover that you seem reluctant to change even though

intellectually you believe you would be better off altering your lifestyle,

then list all the consequences you can think of that would occur

if you did make the specified changes. Which of these would present

new problems for you? How can you decrease your fear of being different?

If this problem seems to have you stymied, seek professional

counseling or medical care.

Refer back to your Action Plan for Change (page 158). Ifthe number

of changes you believe you have to make is substantial, where to start

and how to achieve so much may seem overwhelming. This may give

you the excuse you need to avoid beginning. Do not be upset if you

have found yourself with a long list of changes to make as a result of

reading this workbook. Look at it as a long-range plan. Make a list of

the priorities and work away at it over the next couple of years, rewarding

yourself at each step. Gradual change is better for you than

sudden major shifts in thought, behavior, job situations, etc.

Do not give up. You may review the material and revise your plans

repeatedly without harm. Take your time and remember to enjoy yourself

along the way to your goals.

Tick Season Again: One more reason to avoid tick bites

The Daily Apple™© Volume 2, Number 6

Saturday, June 15. 2013
PGY 40, Day #350

Tick Season Again: One more reason not to get tick bites ... Red Meat Allergy

I found at least one of the nasty creatures on me each day this this week.  Fortunately, none of them had stared feasting on me.  Nevertheless, it is a reminder that this is the time to be especially careful about ticks and the troubles they can cause.

It is is not bad enough that they are nasty creatures that can transmit Lyme Disease, and a long list of other infectious diseases (below), tick bites are now found to be associated with RED MEAT ALLERGY.  So, if you did not have enough reason to protect yourself from tick bites before, you can now add the risk of red meat allergy to your list. 

That's right, you have one more reason NOT to get tick bites.   New science has emerged from researchers at the University of Virginia the associates tick bites with RED MEAT ALLERGY, including, but not limited to life threatening anaphylaxis.  The symptoms of red meat allergy usually occur several hours after eating the red meat, because the offending agent, alpha-gal is most abundant in animal fat, so absorption is delayed.

Beware tick bites!

Have fun and be careful out there.  StepWisely®™© with us and Go to Health™©

Dr. Mike
Michael F. Mascia, MD, MPH

REFERENCES

CDC LIST OF TICK BORN DISEASES:

• Anaplasmosis is transmitted to humans by tick bites primarily from the blacklegged tick (Ixodes scapularis) in the northeastern and upper midwestern U.S. and the western blacklegged tick (Ixodes pacificus) along the Pacific coast.

Babesiosis is caused by microscopic parasites that infect red blood cells. Most human cases of babesiosis in the United States are caused by Babesia microti. Babesia microti is transmitted by the blacklegged tick (Ixodes scapularis) and is found primarily in the Northeast and upper Midwest.

Ehrlichiosis is transmitted to humans by the lone star tick (Ambylomma americanum), found primarily in the southcentral and eastern U.S.

Lyme disease is transmitted by the blacklegged tick (Ixodes scapularis) in the northeastern U.S. and upper Midwestern U.S. and the western blacklegged tick (Ixodes pacificus) along the Pacific coast.

Rickettsia parkeri Rickettsiosis is transmitted to humans by the Gulf Coast tick (Amblyomma maculatum).

Rocky Mountain Spotted Fever (RMSF) is transmitted by the American dog tick (Dermacentor variabilis), Rocky Mountain wood tick (Dermacentor andersoni), and the brown dog tick (Rhipicephalus sangunineus) in the U.S. The brown dog tick and other tick species are associated with RMSF in Central and South America.

STARI (Southern Tick-Associated Rash Illness) is transmitted via bites from the lone star tick (Ambylomma americanum), found in the southeastern and eastern U.S.

Tickborne relapsing fever (TBRF) is transmitted to humans through the bite of infected soft ticks. TBRF has been reported in 15 states: Arizona, California, Colorado, Idaho, Kansas, Montana, Nevada, New Mexico, Ohio, Oklahoma, Oregon, Texas, Utah, Washington, and Wyoming and is associated with sleeping in rustic cabins and vacation homes.

Tularemia is transmitted to humans by the dog tick (Dermacentor variabilis), the wood tick (Dermacentor andersoni), and the lone star tick (Amblyomma americanum). Tularemia occurs throughout the U.S.

364D Rickettsiosis (Rickettsia phillipi, proposed) is transmitted to humans by the Pacific Coast tick (Dermacentor occidentalis ticks). This is a new disease that has been found in California.

   REFERENCES FOR TICK ASSOCIATE RED MEAT ALLERGY:

http://uvamagazine.org/research_and_discovery/article/ticked_off_carnivores/

http://online.wsj.com/article/SB10001424127887324634304578537203916053308.html

REFERENCE FOR PREVENTION AND TREATMENT OF LYME DISEASE

http://cid.oxfordjournals.org/content/43/9/1089.full

CDC LYME DISEASE LINK

http://www.cdc.gov/lyme/

How Does Red Meat Cause Atherosclerosis: New Science

The Daily Apple™© Volume 2, Number 6: The Red Meat, Blood Vessel & Heart Disease Connection

The Daily Apple™© Volume 2, Number 6
Friday, April 12, 2013, PGY 40 Day #262

The Stress Management Workbook covers Diet and Nutrition in Chapter 4, Increasing Stress Tolerance.  Why are we jumping ahead?  There is new scientific evidence to support tight limits on red meat consumption.  This evidence is compelling enough to remind you again to limit red meat.  Don't eat it more than twice weekly.  For some with known atherosclerosis ... don't eat red meat at all and use a form of the "Mediterranean Diet".  We will explain why in this blog.

Proper diet  is essential to optimal health and well being.  In The Stress Management Workbook, we advocate a diet that is "high-protein, low-fat, low-carbohydrate".  That still works for healthy people and folks with no organ dysfunction (such as renal failure), or congenital metabolic defects.  But, the question is this; exactly what should you eat to optimize benefit and minimize the risk?  For otherwise healthy individuals and people with no special needs, here are the key words: Balanced and Fresh! Fruits, Vegetables, Nuts, Seeds, Vegetable oils, Lean meats, Fish, Eggs, Milk, Cheese.  Avoid more than 2 servings of red meat per week and cut red meat out, if you have heart or blood vessel disease.  RED MEAT and lower your l-carnitine consumption and this is why.

We have assumed that the FAT in red meat was the agent that causes disease.  However, new evidence suggests otherwise.  Under proper conditions, certain bacteria in the intestines produce a chemical that is absorbed into the bloodstream and promotes atherosclerosis.  Here is the link to the article for those who are so inclined to study it.

http://www.nature.com/nm/journal/vaop/ncurrent/full/nm.3145.html

This study results by Robert A. Koeth et al, published in Nature Medicine on April 7, 2013 showed that these gut bacteria make trimethylamine-N-oxide (TMAO) from l-carnitine, which is abundant in red meat.  High TMAO levels are associated wtih atherosclerosis in humans and mice.  Cut out the red meat and/or the bacteria and TMAO blood levels drop.

This study demonstrates a few things and suggests a few more to be examined:

1.  Red Meat changes bacterial composition in the gut and promotes atherosclerosis

2.  The presence of "specific bacteria" in the gut promotes high blood levels of TMAO if red meat is consumed

3.  High levels of TMAO are associated with atherosclerosis

4.  Certain diets (without red meat) may suppress the "specific bacteria" implicated in this study

5.  Antimicrobial properties of certain foods may prevent proliferation of "specific bacteria"?

This table will help you understand why red meat is the BIG dietary source of L-Carnitine.

L-Carnitine Content of Selected Foods
Food	Serving	L-Carnitine (mg)
Beef steak	3 ounces*	81
Ground beef	3 ounces	80
Pork	3 ounces	24
Canadian bacon	3 ounces	20
Milk (whole)	8 fluid ounces (1 cup)	8
Fish (cod)	3 ounces	5
Chicken breast	3 ounces	3
Ice cream	4 ounces (1/2 cup)	3
Avocado	1 medium	2
American cheese	1 ounce	1
Whole-wheat bread	2 slices	0.2
Asparagus	6 spears (1/2 cup)	0.2

*A 3-ounce serving of meat is about the size of a deck of cards.

From the Linus Pauling Institute at Oregon State University on L-Carnitine

"An apple a day keeps the Doctor away."  Did you know that, among other things, apples contain natural antimicrobial chemicals?  This study has me wondering how our diets have changed over the last century.  Is our red meat different from the red meat of 1913?  Are we eating antibiotics that change our intestinal bacteria?  Hmmm ... keep on wondering with me.  We will keep you updated as the information rolls on.  In the meantime RED MEAT.

StepWisely®™© and GO TO HEALTH(TM) with us @ihealsolutions.

Have fun and be careful out there.

Dr. Mike

Michael F. Mascia, MD, MPH

The Daily Apple™© Volume 2, Number 5: Signs and Symptoms of Stress (Continued)

The Daily Apple™© Volume 2, Number 5

Thursday, March 28, 2013 PGY 40 Day #249


The Stress Management Workbook (Continued)

In February, we posted the first section on Signs and Symptoms of Stress.  Today, we will complete that chapter. 

Signs and

Symptoms of

Stress

 In our last Stress Management Workbook post (February 13, 2013), we shared scales to help you quantify SYMPTOMS OF STRESS.  Today, we will share the pages that cover SIGNS OF STRESS.

We now go back to The Stress Management Workbook: An Action Plan for Taking Control of Your Life and Health by Aronson and Mascia, Appelton - Century - Crofts / New York, Copyright MFM & SRA 1979 & 1981

Page 11 -  

If your score is high and you have not seen a physician for evaluation of your symptoms, you should do so in order to exclude the possibility of serious illness. If serious illness has been excluded by your physician, there are several other approaches to relieving stress-induced symptoms.  If you scored higher on numbers 1-7, 11, 12, 15, 18, 21, 22, and 25 (those marked “A”), you are more likely to benefit from some active form of relaxation, such as running, jogging, tennis, or some other form of exercise.  If you had a predominance of high scores on numbers 14, 16, 17, and 19 (those marked “P”), you may be more likely to benefit from some passive form of relaxation, such as meditation, yoga, deep-muscle relaxation, or self-hypnosis.  If you have a balance of the two types of symptoms, you may benefit more from a combination of the two forms of relaxation.  (You may have noticed that not all the numbers have been listed in this review.  The reason is that those particular symptoms are a mixed variety and do not tend to fall within either category.)  If the symptoms you are experiencing are debilitating, persistent, or severe, check with your doctor to exclude serious illness or at least the possibility of a need for treatment.

SIGNS OF PSYCHOSOCIAL STRESS

Signs:Objective or observable external evidence of internal, physiological change.  Signs and symptoms sometimes go together to define a pathological condition or disease.  However, some signs are usually representative of psychosocial stress and rarely indicate disease.  A physician may have to make that determination.

LIST OF SIGNS
Increased alcohol use	Changes in posture
Increased drug use	Hyperventilation
Increased tobacco use	Lack of control
Weight gain	Increased spending of money
Weight loss	Reckless behavior
Increased activity	Poor judgment
Reduced activity	Increased sexual activity
Pacing the floor	Reduced sexual activity
Wringing hands	Loss of effectiveness at work
Worried look	Increased eating
Throwing objects	Reduced eating
Kicking objects	Other
Slamming objects

            The following scale is designed to help measure your signs of stress.  These signs are frequently seen with psychosocial stress and rarely represent disease.  Please fill out the following form.

 

 

12                                    THE STRESS MANAGEMENT WORKBOOK

SCALE 2-SIGNS OF STRESS

Please respond to the following statements.

            2                                                          1                                                    X

PAST TWO WEEKS	PAST STRESSFUL WEEKSTIMES
I have or those around me have noticed:
__________ __________ __________ __________ __________ __________ __________ __________ __________	__________ __________ __________ __________ __________ __________ __________ __________ __________	1. I have gained or lost weight. Comment: ______________________________________ _______________________________________________ 2. I have increased or reduced my physical activity. Comment: ______________________________________ _______________________________________________ 3. I pace the floor. Comment: ______________________________________ _______________________________________________ 4. I wring my hands. Comment: ______________________________________ _______________________________________________ 5. I have a worried look. Comment: ______________________________________ _______________________________________________ 6. I throw, kick, or slam objects. Comment: ______________________________________ _______________________________________________ 7. I have changed my posture (for example, hanging head down, shuffling my feet, drooped shoulders). Comment: ______________________________________ _______________________________________________ 8. I hyperventilate (rapid breathing). Comment: ______________________________________ _______________________________________________ 9. I lack control (for example, yelling, intolerance, lack of patience, etc.). Comment: ______________________________________ _______________________________________________

       Yes                                          No                               Do Not Know

                                                                                                                                    continued         

 Page 13

__________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________________

__________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________

10. I have increased my drug use (e.g. alcohol, coffee, tea, tobacco, tranquilizers, sleeping pills, marijuana, etc.). Comment: ______________________________________ _______________________________________________ 11. I have increased my spending of money. Comment: ______________________________________ _______________________________________________ 12. My behavior seems reckless. Comment: ______________________________________ _______________________________________________ 13.I have increased sexual desire. Comment: ______________________________________ _______________________________________________ 14. I have reduced sexual desire. Comment: ______________________________________ _______________________________________________ 15. I am less effective at work. Comment: ______________________________________ _______________________________________________ 16. I have increased or reduced appetite. Comment: ______________________________________ _______________________________________________ 17. I bite my fingernails. Comment: ______________________________________ _______________________________________________ 18.Other ______________________________________ _______________________________________________ _______________________________________________ _______________________________________________

       Yes                                          No                               Do Not Know

                                                                                                                      

Page 14

 

The higher your score in the first column, the more likely you are to be under excess stress now.  The higher your score in the second column, the more likely you were to have been reacting to excess stress at those particularly bad times you happen to remember.  The lower your scores, the less likely you are to be experiencing or to have experienced excess stress.  Remember, if your scores are high and you have not seen a doctor recently, you should check with your physician in order to exclude serious illness.  If your scores are high and you do not have a serious illness, then you are likely to benefit from one of the many relaxation methods described in Chapter 4 in combination with a reduction of the stress load you are experiencing.

            In any case, if the signs and symptoms are debilitating (exhausting), persistent, or severe, check with your doctor in order to exclude serious illness or the need for professional treatment.

and

Dr. Mike  

 

PLEASE CONTACT US THROUGH THIS BLOG, OR THROUGH MY EMAIL ADDRESS Dr.Mike@ihealsolutions.com for COMMENTS, QUESTIONS, OR SUGGESTIONS ...

 

"Have fun and be careful out there!"