Wake up little Suzie

A nurse at the ER stated she was getting more than enough sleep but still feeling exhausted in the am. She is also is attending school, enrolled with army and raising 4 kids. She smokes and has had an issue with constipation ok with otc softners in addition to her kids needing the same otc's. (over the counter's) My first suggestion was to get a sleep study in order to determine if an abnormal sleep waves could be causing a dangerous problem. She apparently doesnt snore, is not falling asleep at the wheel, not suffering from memory issues and not being awaken by anything in the bedroom environment. The Saguil Approach would be to first teach about sleep hygiene so she can better understand the issues that cause problems. Sometimes when patients understand the pathophysiology of and injury, they may be able to better find the reason that I can't see on the outside. After making sure no dangerous sleep issues are going on, valerian would probably help reduce her reaction to the stress of all that is going on. I would always suggest omega 3 for fighting any unseen seasonal affective disorder (later told me she is on an ssri for chronic depression that is "stable"). The cigarettes have to stop after dinner, caffeine should be tapered to nothing after lunch. I always suggest an early morning wake up alarm the same time 7 days a week. An evening ritual one hour before desired sleep time is also important to start. My experience is that grad students in the same scenario always suffer from and exacerbation of old symptoms in the last year of grad school. Best I can do is make sure nothing dangerous is occuring and provide some supportive suggestions until 3 months after graduation. This would be a complicated patient since there seems to be underlying issues, (chronic constipation, tobacco addiction and multiple endeavors with over extension of normal daily duties). Good thing is she is plugged into other specialists for each issue, bad thing is all these guys are doing there own thing without concern for the other body systems. This is typical for western medicine, treat the disease process not the patient. The brain, the body and the spirit arent considered one. This is where the spirit, would be the biggest component that if worn down would effect the normal functioning of the other body system (speaking on western terms). Truth is I could make anyone go to sleep with the right potent drug but if the true reason isnt found, more and more meds will be needed in addition to other medicines to reverse the side effects from the sleep drugs. We should just hibernate through the winter and wake up in spring, thin with grown kids.

Do I have to take a vitamin?

The american dietetic association is conservative in its suggestions to the public about nutrition in the US. With gas prices forcing people to work longer hours or second jobs, most americans who ate poorly before are now diving into fast food, stress eating or binging after a 12 hour shifts. Kids will follow when at home by themselves or in the care of a non-kitchen friendly guardian. (My brother in law used to joke by saying he would watch the kids by pouring a large bowl of cereal and placing a few boxes of juice box drinks in front of the tv/xbox for the time I was at work....I still wonder if he was kidding or not). Poor nutrition with higher stress living asks the body to go into fight or flight for extended periods of the day. An average human will have enough endorphin and adrenalin to sustain bursts for about a day but then after that, body store depleation. That would be depleation of glucose, glycogen (sounds good for weight loss!) but also neurotransmitters, body steriods controlling bodily function (like pooping, eating, concentration and sleep) and then those nasty hormones responsible for laughing, love and good sex.

Bottom line is that we learn poor eating in high school, keep it up in college, take it to work and teach it to our kids. Vitamins are necessary to sustain a basic level of function when an adult is eating 4 meals of low cholesterol, low fat, high fiber with 3-10 pieces of fruits and/or veggies daily. The average person reading this doesn't eat that way. Personally, I have to go to whole foods, dominics, jewel and target to find the best choices for fruits and veggies and not go broke every month. I like to say I do it for my kids but my fibromyalgia is under control, back pain is gone and I can still do 60 minutes of cardio with 30 min of yoga without needing medicine for blood pressure, inflammation or joint pain.

All these diet and supplement suggestions you hear are for an average american with an average diet. Those that carry medical problems and take medicines to control them need more supplements. (My average patient seen in the ER has 2-3 medical problems, 1-2 medicine they are taking and is under 45 years of age.) It funny that the average patient on cholesterol lowering medicine doesn't follow a low cholesterol diet! Average patient with early diabetes doesn't know how many calories or carbs they are taking daily. Average arthitis sufferer doesn't loose weight or participate in yoga or taichi.

Watch my next post to figure how to pick a supplement.

Are there any sideffects to taking advil?

Healthy young man who exercises 5 days a week for about 1-2 hours came to the ER with acute onset of abdominal pain monday. No other history of medical illness or problems like this before. No history of gallstones, pain not worsened with eating, no change in stools or urine and it hurt to take a deep breath or twist. no fever and no other new activity in the last week. No history of heart disease, cholesterol,high blood pressure and I bluntly asked about drug use and he said no.

I was worried about lung problems with an old history of asthma as a teen but physical exam was normal. Then he remembered he was in a motor vehicle accident about amonth ago and air bag did get deployed. he doesnt remember any pain like this but when asked further, he does admit to taking advils daily since the accident. No history of ulcers in the family and no tobacco or alcohol use. (he works as a banker in a high stress position but he didnt know his blood type- type O has higher chance for ulceration). I was confident he had an ulcer but he wanted an xray anyway. The radiation exposure resulted in a normal xray as I told him it would. The GI cocktail, which usually brings down ulcer pain immediatedly only helped a little, brought 10/10 pain down to 8/10. I told him he should be ok with Prevacid and avoidance of advil, coffee, alcohol for 1-2weeks but his mother wanted to get a surgeon involved. Surgeon said she wanted to scope him to look for the bleedin ulcer and asked a slew of questions on blood tests, imaging studies......All very valid for ruling out life threatening disease and I had no problem ordering everything except the surgical procedure. I pointed out that his physical exam did not point to a bleeding ulcer but a mom that works in trauma surgery is sincerely worried about her son. Ultrasound showed no problems with liver or gallbladder, blood tests reinfored the fact he wasnt actively bleeding from an ulcer, kidneys electrolytes and liver functioning was all normal. He did note that as he waited for the blood tests results and ultrasound, pain continued to get better. The only thing I gave him was a cocktail of maalox, benedryl and lidocaine (numbing medicine for the lining of the stomach).

Advil, ibuprofen, motrin are all the same. They are nonsteroidal antiinflammatories that work to reduce pain sensation by reducing inflammation. One problem with this medicine is that it also decreases stomach mucous production and leaves the lining of the stomach unprotected from its own acid causing the eating away of spots in the stomach (ulcerations). Stomach should be able to protect itself and heal up fast. The lining of the stomach is very quick to regenerate/grow, but with daily exposure to advil, stress daily -(stress tends to cause over production of acid), and indulgence in caffeine and coffee, and most likely stimulants in energy drinks for exercise, ulcerations continue to grow and get deeper. I believe the delay in response to the cocktail meant he had a large ulcer or one in the duodenum more so than the stomach. (the duodenum is the part of the intestines that the stomach dumps food into once it is finished with digestion, sometimes contents are held in the stomach for a few hours before they move onto the duodenum/intestine. Likewise, an ulcer in the duodenum is more important than the ones in the stomach since vital blood vessels are right behind the intestine and a hole in the lining can eat right through to the blood vessel. (big mess) The other bad thing the advil can cause is pain relief......yes good for pain from the airbag hitting the man but bad for the ulcer which usually results in pain saying to the patient...hey, dont take that advil anymore!but with less pain from the ulcer, he doesnt realize what hes doing!

Celebrex was made to be so specific for inflammation and not to hurt the stomach it was thought to be a miracle drug for inflammation especially in ulcer sufferers. Great news till we found it caused heart attacks! Funny thing was when the studies came out, a warning from the celebrex companies came out saying all antiinflammatories medicines could cause heart attacks so avoid all of them. Seems to get the attention off celebrex and place it an the whole antiinflammatory drug class. (see how studies can be misinterpreted or specific portions of studies can be stressed and others ignored depending on who is reporting!)

I'm not just coming down on prescriptions, evenherbal medicines have side effects (like liver failure-see my earlier post on the adventrues of Dr Saguil). Just know what is going in your mouth and dont trust everything you read. When possible, rely on food and healthy living, use supplements wisely and always question the doc, pharmacist, nurse about what you are taking.

My "achin" knees

So my daughter was in class and heard a sudden....eyyyyyooowwww!! Teacher then exclaims, does anyone know a sportsmedicine doctor.....index fingers proceeded to head to the general direction of my offspring. Apparently the teacher, Mrs. M was getting out of her car and as she placed her foot down, one of her knees (probably the knee cap or patella in particular) caused a sudden excruciating pain but then backed off and just ached from that point on. Improvement is probably already happening but with certain positions, the intensity returns just like the car, immobilizing her suddenly then leaving as fast as it came.
I didn't get much more information from my daughter but don't need it. As I always preach, 80% of a diagnosis can be attained from history taking alone. Physical exam backs up the history/diagnosis and tests like blood or xray support the physical exam. In 14 years I have come accustomed to the usual issues that befall the knee. With no preexisting issues like arthritis or surgery, the standard history like this is most likely a patellar injury.

To review the anatomy of the knee, we have a hinge joint like a door that opens and closes. Very simple movement, but this joint in particular is complicated in that it must be able to jump and sprint like a rabbit but at the same time be ready to hold in place up to 200 to 400 pounds (all this for an average of 70-80 years). The two big bones that make the knee are the thigh bone (or femur) and the shin bone (the tibia). These two bones rest on each other with little wafer-cusions (cartilage)between them. To be able to move these bones in a hurry and hold a great quantity of weight, we need long but thick muscles (the front thigh or quads). The Quad muscles originate from around the hip and insert to a small point on the shin. When the leg is straight, quads are straight, when the knee is bent like a squat, the muscle has to rub against something to get from the hip down to the shin. Like a spagetti noodle rubbing over the edge of a fork, it will eventually break so our creator made this thing called the patella that helps guide the muscle over the rough edge of a bent knee. This knee cap (patella) has a smooth surface that comes to a point like the bow of a ship. This bow sits in a groove in the thigh bone. As long as the "bow" is in the "groove" muscle works well, we sprint and lift weight without a problem for 80 years.

Great architecture right? Yes except for when the knee is bent and then is pivoted slightly. When the "bow" of the knee cap has enough force in the wrong direction, it will slip out of the "groove" and crack, scrape, chip the edge of the bow (knee cap). This smooth surface that coats the undersurface of the patella is very delicate and when a large ridge of bone pushes up against it, the soft surface dents, cracks, rubs off, chips. Next time you eat a thight bone from KFC, looks at the white soft cartilage that lines the joint you just broke open. its softer than bone but harder than muscle, easily chewed (or dented,scraped,rubbed,chipped).

I think with her mechanism of injury, our teacher, Mrs M. has suffered a patellar chondral contusion. (Bruise to the cartilage of the knee cap). As with all bruises or scrapes to skin, it takes about 10-14 days to have that scab fall off and skin to heal up right? Well in the case of a knee cap scrape, the knee is constantly being exposed to friction while we are asking it the heal up, this postpones the healing process. Keeping the knee straight (like "Fester from Gunsmoke" or "Madmax" from the Mel Gibson movies) will allow the patella to heal faster but without a big knee immobilizer and crutches from the ER, it's hard to remember to keep the knee straight. What usually happens is we have great intentions in the morning but as the day goes on, occasionally we get into a bad position and eyyyyyoooowww! That little scab to the backside of the knee cap tears open again and then its another 10-14 days of healing.

The Saguil Approach is to use ice during the first three days for 10 minutes at the top of every hour. After that its 10 minutes three times a day. An antiinflammatory is helpful and the good ones can be prescribed by me or the over the counters are sometimes used, (but I think they cause too much stomach upset.) I like using supplements like IF relief from Natures Sunshine or Zyflamend from New Chapter. Anything with turmeric, boswelia, white willow bark, shark cartilage, oregano...all good for speeding up the healing process. Acupuncture works great! (but it is a temporary relief while waiting for the "scab" to heal. Arnica and tea tree oil help. It always is useful for the physical therapist to show you some exercises to strengthen the quads and keep them holding down the patella in the right position. The gifted therapist who knows Maconnel taping can assist the knee cap in staying in the right "groove" for as long as the tape stays on the skin. When this fails and pain continues to the 3-4 week mark, time for xrays and a possible mri. The problem is; the only true way to diagnose a patellar surface injury is to visualize it directly with a surgical scope. Most of the surgeons (and me included) will try a steroid shot as a last ditch effort to reduce inflammation before considering surgical evaluation.