Frequently Asked Questions

Work Injuries....what a pain in the back!

2010-01-27T22:08:00.000-08:00

Got a call from an athlete that suffered a back injury. I love athletes! (It is so inspiring to see someone who loves to exercise, even if it means postponing other things in life) The irony is that in the doctor world, (when I worked with University of Central Florida), I had to hold athletes back from exercise with threatening scholarship status until they were fully healed. At the opposite end of the spectrum, the typical workmans comp patient is looked at as a potential malingerer. It is ashame but I think some large industries treat the worker as expendible, if one is injured; either get them back to work ASAP, or get them so they can be "let go". (In the last 15 years, I've learned much about doctor patient rapport, I have found when the bond of compassion and trust is not entertained in the exam room, there is no way that doc will make the best choices/decisions for the one that is suffering). Case in point-in my old private practice, I saw alot of patients, I had to since I worked for the hospital and I had to produce patient hourly turn over that matched the rest of the country. If I saw less than average, I was "wasting time" or "talking too much". Imagine that, a doctor trying to get the most information out of the encounter by talking too much and being penalized for it. If- as I walked in the room, I already had the idea in my head "I gotta get out of here as fast as possible" I am not going to pay attention to your symptoms or suffering, I will get a few bits of info the nurse got from you and write the best drug that works the fastest! How about this: if I meet and greet you as your doctor but the lawyers say you can potentially bring me to court with a malpractice suit, how am I supposed to feel compassion for anything you are telling me about your sickness? Without compassion, I'm not going to care about details or how your family is being effected or how you are sleeping. This is why I left private practice (.....but more about working in an ER.....watch for future posts)
Any way, nice guy calls to inquire about acupuncture and he is willing to go outside workmans comp and pay out of pocket just to get better fast. Very admirable! Seems he hurt his low back with a heavy lift and was seen by a PA, then a Doc, then sent to PT and discharged after about a month. Now back to work, light duty but still in pain and not fully aware of any follow-up. When I dismiss or as I call it "graduate" my patients from my care, they should have the recuperation plan memorized back and forth, the diagnosis, the maintenance exercises, the use of medicines and what to do with flare ups. Looks like none of this was given to the patient, poor guy!

(big inhale....) well..the studies say the average back pain at work is caused by a muscle pull. "Mechanical low back pain" as it is called in ICD9 coding. Since it is muscle, it should heal up fast. If a broken bone heals in 4-6 weeks, a back muscle should heal up 1/2 the time. To make it heal even faster than normal human speed, we use medicines like steroids, muscle relaxers, narcotics and even injections into the muscle or spinal column. This with physical therapy should get an injury back to normal. If the physical therapist feels there is no progress, the doc instructs him to do a FCE (functional capacity evaluation) and if given a "good effort" and if the patient can't perform the activity required for the postition, he will be let go or terminated-unless there is a lighter position available. It seems very harsh but there are some who really milk the system and refuse to return to work and claim disability costing the country millions of dollars to feed them the rest of their lives. It is because of the few that the majority get scrutinized.

Anyway, if the therapist did his job and did all that could be done to help this patient, and the occ med doctor has released him......muuhahaa....now it's my turn. I evaluate the foot stance, knee position, back flexibility, spine curvature, gait with normal walk and then if possible with the sport of choice. We look at muscle development, baseline flexibility, nutrition status- and with we I mean a physical therapist with a dedication like what I have to helping. I like the therapy centers with employees that also teach or partake in pilates, yoga, taichi. The old physical therapy centers that were (big chains) of centers from the 90's, I felt didn't have the quality of the privately owned ones. Those are the centers that put you on a bike for 30 minutes or warm compress for 20 minutes and there goes half of your visit. Then obviously, when poor progress is made in therapy, patient gets sent back to me as a failure and a surgical opinion has to be made, or stronger medicine prescribed or steriod injected or all the visits allowed by insurance have been maxed for the year!

What I would do is all the above and then comes the integrative medicine, acupuncture works well to "cool down" spasm. Note: it only provides an opportunity for the patient or the therapist to rehab more aggressively. Herbal medicines work in conjunction with prescribed meds to heal the muscle. We all know antiinflammatories like advil, motrin, aleve, naprosyn....how about oregano, turmeric, frankinsense, devils claw, glucosamine sulfate, helicrysium....or even high dose vitamin D? Fact is that the average american diet stinks so much and better than average nutrition is needed to heal better. The average athletic diet is lacking in calories. Average vitamin supplement (GNC) doesn't get absorbed or doesnt contain what is written on the label. Even the mind body part of healing is very rarely utilized. I used to know a sports psychologist in Wheaton but only the elite athletes would go because every one always said "I don't need a psychologist, I'm not depressed".....oh boy, the education I would have to give.

Bottom line is when the body mind an spirit are functioning optimally, the injury and pain will go away with light speed! Yes, back pain is just muscle that is spasmed, but due to the pain, walking, running, biking, swimming, or just sleeping and breathing are altered. Then attitude is altered, then peace is altered, then relationships are altered, then time at the gym is altered....then there is anger and distrust....then everything is painful or someone elses fault.

Always report (sometimes on a weekly basis) how the injury is even after discharge. Live life "post injury" different than before. I always say, if you never worked on flexibility before, from this point until you die, you must now incorporate that into the daily routine. Optimize on nutrition for the time of rehab and for at least 3 months after discharge. Never return to competitive training until all pain is gone. (athletes develop engrams that make the body learn poor or compensated technique, -just a set up for another injury). Always go outside work comp and seek out complementary and alternative doctors. You may have to pay but just do it. Try not to listen to "the mind" when it says....you did this weight, distance or speed before, so just try it while you are still injured. Adrenaline and epinephrine are fight or flight hormones and will make you do stupid things. This is why I meditate, I can control fight or flight and substitute it with oxytocin, serotonin and all the peaceful hormones, this leads to better decisions, judgement and outcomes. (Ghandi, Jesus, Buddha...). Cross train in a sport you never liked before during the down time of the injury. Likelyhood is, if you do a sport you never liked, you will develop different muscles, still keep the heart in "shape", and it may make you a more well rounded athlete in the future. Finally.....Visualize and MEDITATE!

Is it really organic?

2009-10-26T11:44:00.000-07:00

Had a discussion with a cousin of mine who happens to be an Ex New York Chef and the topic was, what is organic. Tom carries the persona of a New Yorker with blunt force grace and respect. He is also a great chef. In the typical new york accent, he came out with, "even if a product says Organic, who is to enforce the delicate cultivation of the organic produce or livestock?" Good point right? Well, I alway choose to trust in a higher consiousness and take the high road to feeling that most of mankind will have a good heart and do the right thing. I dont doubt the possiblities of people cutting corners and doing what they think is necessary to survive even if it means mislabeling. (To me, in the end, we attract what we are- live life with bad intention and bad will come to you...)

The Organic Foods Production Act was passed in 1990 as part of the Farm Bill. It has morphed into the National Organic Programs definition and rules published by the USDA in 2000. In order to label as organic, farmers and producers go through a lengthy and detailed process. On the contrary, to label as natural, there is no verification process except for meat and poultry (regulated by the Food and Safety and Inspection Services. All organic foods must be produced without antibiotics, synthetic hormones and genetic engineering. If you ask why antibiotics and hormones......imagine 100 people living in one single family home-in the basement. These 100 people are asked to eat 3-4 times a day to get fat, the women are asked to pretend they just gave birth and start lactating, they are asked to stay like this for a few years and not get sick, poop in one place and listen to the sound of other humans before them getting killed in another part of the house. Stress makes us not want to eat or lactate so we would get hormones. Close quarter living produces infection thus the need for antibiotics (several times a year depending on the season even if the basement is warm). Poor dieting on corn meal makes us have heart disease and arthritis so more medicine so we survive until slaughter time. Of course the weak get killed early and chopped up to be placed into the feed for the 99 remaining people in the basement. (I am getting grossed out writing this)

The organic eqivalent would be 100 people walking around outside, getting better food, regular check ups, and in the case of "Kobe Beef" brushed and given beer daily on a green pasture. See the difference? Less stress, less sickness, true bonding with children (cow calf) to produce milk, more exercise on open plain.....The value of you are what you eat can be extrapolated down to the stress free life of the product you are eating and that goes for fruits and veggies too. In India, China and some Native American lands, before the herb is harvested for medicinal use, the farmer will say a prayer of thanks to the earth.

Now comes the breakdown. 100% organic means the item is composed entirely of certified organic products. Organic means at least 95% of the item is composed of organic. Made with Organic ingredients means it is made of around 70-94% certified organic products. Ingredient panel only means the food has less than 70% organic ingredients.

USDA

Organic products are more expensive, 15-60% more depending on where you buy. I like Whole Foods Market and this is probably the most expensive around my area. I may pick and choose the most important items to come from WF (the food I need to taste the best for my kids) and the not so important one I pick up from Jewel/Osco or Dominics. Some of the things I feel don't have a high organic value would be my oranges and bananas. The peels keep most toxins out. I also use in season coupons (don't tell my uncle, he says real men don't shop with coupons...but then again, he had a heart attack)

Ashleigh Eisbrener put together a nice list of what to buy and not to buy organic. Here it is:

Buy:

Apples
Celery
Cherries
Grapes
Ketchup
Lettuce
Spinach
Strawberries
Tomatoes
Nectarines
Peaches
Pears
Peppers
Milk (although I really suggest almond milk)

Not necessary Organic:
Asparagus
Avocados
Bananas
Brocholi
Cabbage
Corn
Kiwi
Mangos
Onions
Pineapple
Peas

To cut or not to cut.....that is the question.

2009-10-16T08:11:00.001-07:00

Now that I finished the marathon, I am back to blogging. Didn't relaize it has been the whole summer but good to be inspired again. On the phone with my local law enforcement friends today and just happened to hear a sliver of an illness. Of course for those who have met me, I had to start my "interrogation". (the kids will attest to the fact that if I hear anything medical come up in conversation.....there I go...blablablablabla). So "lady T" had a very common ailment of right upper quadrant pain. With traditional western medicine, we think of the body part and not the person so I already had a diagnosis and treatment for her. (And all I heard was 4 words..pain, abdomen, right side....western medicine has programmed me to be so uncaring that if I was rushed in an office.....I would stop the conversation and write a script!) Of course being the compassionate doc that I am, I listened more to "lady T the person". I knew from her voice she had patience, experienced with the stress of triage, hestitant on going to the doctor. (I don't blam her....I dont trust doctors....especially ones who force me to take swine flu vaccinations so I dont infect others with an illness I don't have from a vaccination that has been fasttracked!) Don't have to get into the details of the complaints but it brought me to this point. During holidays, especially in this economy, stress is high, exercise is low, sunshine is gone and hot foods and coffee are a-plenty. In considering all of the above, people with gastritis/ulcers/stomach irritability will start to blossom about now, full bloom will come in the days between xmas and new years. We as a society are putting nasty things in our mouths that were never meant to be created. Foods are genetically engineered to taste soooo great and make you feel soooo great for a short time. Then there is the remorse of "I can't believe I ate the whole thing", or "I should have stopped at 2", or "I am going to have to fast for a week now" or "now I will have to spend 500 hours on the bike". Well, the ramifications to bad behavior are: stomach upset. The body knows what is healthy for it and will let your brain know...."this much coffee is not good for you so I am going to gnaw at your right side for a couple of minutes every hour". Stress of winter season also brings sickness to the community, people missing work and staying home, having to fill in for extra shifts, fielding complaints from others who also feel lousy, more anger on the highways causing accidents and traffic jams, leading to being late for work, eating lunch too fast, having more indigestion and side pain,not being able to concentrate at work leading to poor sleep and getting sick....etc.
Without coming up with an exact diagnosis, the first thing I would try to get people to embrace the comforting things of the season. Nature has built so many things that help us through the dark months. Think warm fire, soft blanket, comfortable slippers, roasted nuts, warm cocoa, cuddling with a love one to stay warm, seasonal holidays with family. There are great answers to stress that we kinda just save for snow days but should be taking advantage of now. At Harvard, Herb Benson taught me that meditation and the relaxation response will take care of the majority of stress related illness without even prescribing one medicine. No doubt, this is difficult to learn and doesnt happen overnight. I now put on my western doctor hat and tell most folks, I have the power to make things go away in seconds with chemicals that may kill you, but if you are in a hurry and have prescription drug coverage, I am there for you! (Such an american answer to treat the symptoms fast and not worry about the cause) And while on the topic, you should always see a doctor for other possibilities....gallstones, kidney stones, liver disease, cancer. In fact, most docs due to the emminent threat of being sued, will initiate the treatment plan saying, it may be these other diseases but I will treat for the most common one first so don't think about cancer or surgical extraction of a gallstone. Like saying, "you can drive my Porsche, and it has alot of horsepower with a difficult to control midengine oversteer that will cause you to lose control and hit the median and die but that probalby wont happen so enjoy!" As Wayne Dyer says, don't let the negative meme (thought) enter your mind to begin with.
So back to belly pain, the fast answer is stress equals poor digestion and stomach erosion from increased acid production. Chronic over production of acid by the stomach will digest food but will also digest itself. Yes, if the stomach has an imbalance between the mucous lining it makes to protect itself and the amount of acid it makes to digest the food it carries, ulcers happen. These start as erosions/scratches/rough spots on its lining. With continued acid production, poor mucous production, high ingestion of damaging foods-coffee, caffeine, tomatoe, chocolate, advil, alcohol. The erosion/scratch/rough spot will grow and become louder. Symptoms will go from a gnawing to the solar plexus to radiating pain from the right side to pain to the right low back. Food will soon become irritating to the pain loose bowel movements occur, sleep gets interrupted early am.....Fast treatments would be avoid the foods mentioned, pepcid or zantac twice a day for 2 weeks, smaller meals more frequently to avoid overstretching of the irritated stomach. Some docs go straight to the "proton pump inhibitor meds like prilosec, prevacid, nexium. These are very powerful and shut off all acid to help heal the lining. Problem I see is that docs prescribe but don't advise diet change. So bad habits continue and patients get placed on strong meds for years. I tell all my patients, the ppi's(proton pump inhibitors) were release with a warning not to use past 3 weeks. No acid means poor digestion, bad bacteria overgrowth, poor mineral, vitamin and antioxidant absorption, poor healing and poor health. Food products like fennel, peppermint, ginger and anise have always been used to "calm" the stomach and act as "carminitives". I have acutally picked up a tea blend from Teavana in the Woodfield Mall containing: peppermint, chamomile and green tea-great for coffee substitute and warm with the antioxidant EGCG. Avoidance of very difficult to digest meat and dairy products for about 2 weeks also important. If no response, I have several treatments in acupuncture that would help in the healing process in addition to digestive enzymes until healed. There are also very good practitioners in reflexology, reiki, and some chiropractors who can help initiate the healing process with hands on healing.
I always welcome radiology studies like ct scans of the abdomen, ultrasounds of the gallbladder (especially with a family history) and maybe even kidney tests. One caveat is if there happens to be a stone in the gallbladder that was incidental and the pain is present, a surgeon will always say, when do you want to schedule for surgery? One may or may not need to be cut but the squeeky wheel always gets the most oil. "If you complain, he will cut it out".
A final note is during this time of year, meditation for 10-20 minutes twice a day will alway help your reaction to daily stressors. Depak Chopra suggests deep and quiet meditation at least 20 min/twice a day. Herb Benson suggests do it when you can "mini's". I like to include breathing 4-7-8 with yoga twice a day and it helps me smile for an entire 8 hours of working in a busy emergency room during peak H1N1 season (which will be another blog!)

What is Integrative Medicine

2009-05-14T01:45:00.000-07:00

Some of my best friends will ask the question. Without getting too boring, I could tell them the life and times of Andrew Weil. That usually is the long winded approach. I find myself trying to justify my endeavors by speaking of the mans credentials. Harvard College, Harvard Medicine, NIH, Botanist, Author and world cultural traveler, founder of the University of Arizona's Program of Integrative Medicine and Fellowship with graduating classes since 1994. By this time, most time efficient doctors will be answering other questions. Most lay-people will have tuned out after the Harvard names. If I say, he's the founder of a branch of medicine that gets people off perscription drugs, then ears perk up. Most people envision and doctor that will say "ok, the data is out there that medicines dont help so stop everything and go about your normal routine". Little do folks know, the concept he sticks to is to add the physical, mental, spiritual aspects of medicine in addition to special attention to nutrition. Using food as medicine is a old concept but with all the RCT's (randomized controlled trials) that are being quoted, referenced and repeated in medical circles and magazines, basic nutrition really doesn't make the trillion dollar profits for small organizations so it's not spoken of. Doctors don't have the time for nutrition counseling and in many cases, one's medical insurance will not cover a referal to a "dietician" unless the disease is already being manifested. I uses to always refer my patients to the dietician in my building back in the 90's and I distinctly remember when Sandy Gifford had to turn away petients due to poor coverage. (she would still see my patients and educate as best as possible on her own time because of our relationship) ......in fact, doing things on personal time seemed to be what I always had to result in for getting around the limitations of insurance. Up until the time I stepped away from a 10 year practice with retirement just to send a message to the hospital that the patient is the bottom line not the dollar.
I know I was right mostly because of the feedback I still receive from old patients...even until now and I left my practice in 05. Patients are still feeling short changed from the time constraints of conventional insurance based medicine. Patients are also being given bigger and stronger drugs and several of them. I was aware of "laundry lists of medical problems and perscriptions for the elderly in nursing homes in the early 90's but now I am seeing it in 40-50 year olds(hypertension, diabetes, cholesterol). I am also seeing it in 10-20 year olds (adhd, diabetes, asthma). Now within the first year of life (reflux!).
As usual, there has to be a coexistence, modern medicine is great and very powerful. Trauma, rapid reversal of heart disease, cancer, kidney failure, premature birth, having 8 babies. But I think we are forgetting about nutrition, exercise and stress relief. This is how I see what I do is correct. To integrate old fashion health care with modern disease care is a must. Health care has to be individualized. Humans are so dynamic that everyone can't be labeled as a hypertensive or diabetic. I like what Chopra says regarding a new paradigm in medicine. The last few decades, medicine was so boastful to think if we knew the pathophysiologic pathway to a disease, then we could fix the disease by treating the pathway. Obviously this was the wrong thinking and now there are small fixes for every symptom in the world without fixing the mindset of the indiviual coming to us for the ailment/symptom. When I used to hear the term holistic medicine, I would think of someone who had little training in healing that people were going to in desperation of a better answer than what the doctor would tell them. Now I understand more about the best approach to healthcare and through the efforts of Dr Weil and others, the volume of people (healthcare and non medical) are "buying" into treating more than just a symptom or test result. Thus the idea of "integrating" mind, body, spiritual, environmental and nutritional thinking into the treatment plan. Hippocrates, the father of medicine said to use food as medicine, funny that its getting back to this!

What are growing pains?

2009-02-18T17:50:00.000-08:00

I remember in residency, when seeing a child for a knee pain or limp and the evaluation was normal, I would usually say "growing pains". The moms and dads would already have heard about the diagnosis but would be at ease when I would agree. I would compare this to seeing a 40 year old male that comes in for left sided chest pain and I clear him of heart disease then say its just "stress". To throw all the potential diagnosis under one obscure title of stress is not acceptable to an intelligent educated american. Same thing with the diagnosis of growing pains. In the case of my nephew who is 6, his doctor said the limping he was suffering from is probably just that. This is probably true but I think an educated parent would like to know a more specific diagnosis. When the knees are painful, we worry about the patella. Sometimes worry about Osgood Schlatter Disease where the thigh muscles (quads) stay tight and the thigh bone (femur) gets longer. This would make the muscle pull at it's insertion points on the knee with more force causing a lump to form.

In some cases, knee pain and a limp at my nephews age could be something worse like Perthes Disease (or at a later age, a SCFE). Both of these are not common but since the results are bad, they have to be considered if limping doesn't go away or gets worse. Little James just started baseball 6 weeks ago which makes me feel better that we have a reason for the pain but I will probably be getting an xrays later. (Don't like the radiation exposure but I'll watch him closely and did ask my cousin to video tape his training next time.)

As my patients know, history is 80% of the diagnosis and I think baseball will be the reason for the pain (overtraining). The Saguil Approach is to start with a working diagnosis, evaluate for abnormality, watch the training pattern, surface and shoe type, consider an xray, rule out groin issues and consider 1-2 weeks off to see the results. I suggested that if it is due to baseball practice, try childrens motrin/advil three times a day the day of and the day after practice. Pain that breaks through that conservative treatment will mean we have a bigger issue to be investigated faster.

To note, if there is no limp and just complaints, may consider "secondary issues" like he doesn't like the sport or the coach, or worse, there's a bully around.

Does a normal Cholesterol level mean I have no problems with my heart?

2009-02-05T01:33:00.000-08:00

Usually in the ER, patients will come in with a high blood pressure reading, slightly overweight and a history of smoking. After I comment about please rechecking this with the primary care doctor, the defensive answer is I just had a normal physical and normal cholesterol level. Ooohhh my gosh! I think it is the fault of the medical community in giving false hope that chasing a number keeps people healthy. I admit, with the short time we have to discuss, evaluate and treat symptoms in my exam room, it is easier to give a temporary "bandaid" to an effect of the disease and not the cause of it. Perhaps in the next decade, we can have doctors that fix things fast but medical advisors that guide people to make life changes.

Focusing on heart health, cholesterol is a good parameter to check in blood testing at the office once or twice a year but healthy lifestyles and habits will make permanent changes so that you may not have to ever check another blood test ever! (My doc friends are going to hunt me) This is what I believe and I walk the walk, I am a protector of life; family, friends and patients. If people are giving out poor medical or dental advise, I work to educate the patient on other options, natural healing and healthier living. I believe we doctors are giving a false sense of security to people when just controlling cholesterol levels and not making suggestions for life change. The reasons for bad health are multifactorial; can't change the world with one visit. Sometimes it just takes proper planning over the course of time. Building a practice from scratch seemed harder than moving a mountain. Now that I have utilized those around me who have the same passion for helping others, the task at hand seems so easy. (We could have opened a clinic right down the street from the old place, with less overhead and more life breath coming from the physical location never seen before!) This reflects one of my beliefs that when the world is viewed with reservation and contempt, a "black and white" picture will be seen. When viewed with love, faith and energy the colors will be infinite.

Just don't believe maintaining a normal cholesterol level will keep you free of disease. Strive to improve your health, diet and mind even with normal tests. Push the envelope with what you can perform with your body and mind, find a good doctor, dentist, trainer, therapist and life partner. Together we can change the world! There will always be bad economies, bad debt, bad medicine and bad people around but when we all lock elbows together, our concepts and faith are indestructible.

Check out this blog for other things to do in getting that heart healthy;
http://saguilapproach.blogspot.com/

Bioidentical hormones

2009-01-23T20:48:00.000-08:00

At the Whole foods lecture someone brought up the question about what can I do with wt loss and other symptoms of menopause? The question was more of a hormone issue. (If the "menopausal" symptoms where controlled, good possibility that the weight wouldn't be as much an issue).
We are taught in medical school that all women go through a phase when the ovaries will stop working. Their role in life is to make ovum (eggs) once a month from 16 to about 45 years old. Once they have reached 45, usually the organ will slow down and stop making eggs and the hormones. When hormone cycles that have been in balance for 30 years between the brain, the ovary and the uterus stop, other organs that have had the pleasure of being bathed with hormone will cry out and say....wheres my estrogen!...wheres my progesterone! Brain goes through problems with function- memory, emotional lability, sadness anger temperature lability, muscles go through atrophy, fat depots go through accumulation, adrenals go through fatigue, sex organs ....well later on that one. As docs we are taught if the symtoms are there, check a blood test and if the hormone is missing or low, replace it! In theory, having what you where lacking should make the symptoms all go away (until you get tired of the pill or get a side effect -cancer) Many women did well as far as we know but then society as front loaded the majority of women's attitudes to say what you are feeling is normal, you have to go through it and your only choice is to take the hormone.

Here is the reveal: you can't "cookie cutter" humans! Different people have different presentations and although the blood levels will be fixed, the person that was suffering slightly before menopause hit will still be suffering after the hormones are taken, and some of those closet symptoms will not go back in the closet. If the doc doesnt take 10 minutes to listen to what you are truly suffering from, it will be missed so get a new doc!

Diets can be changed, exercise can be changed or introduced, lifestyles can be dropped or started, supplements can be taken. Even the hormones can still be used but perhaps a bioidentical can be tried before the standard pills are tried. Everyone has probalby heard about how "prem____" the progesterone substitute comes from purified horse urine. I say leave it to the horses! By contacting a local pharmacy that compounds, you can get a chemically derived hormone look alike. Investigating these guys would be what I suggest.....

-while in Florida I used Pharmacy Specialists 393 Maitland Avenue. Altamonte Springs, FL 32701 (407) 260-7002.
-here in Illinois, Martin Ave Pharmacy, 1247 Rickert Drive, Naperville Il 60540 (630) 355-6400

...and both places will ship, just need a script from the doc.

Anyway...the lady at the lecture mentioned she tried bioidenticals but have a hearing issue. (That would easily be fixed with acupuncture) but this should be brought up to the doc and the pharmacist. I think she was in the right direction but just needed a little guidance on what else to be looking for. I forgot to ask her that even through the hearing issue, how were the symptoms of menopause with the bioidentical? Bottom line, checkwith the insurance and if covered try them out....like having a custom made suit versus an off the rack.

Wake up little Suzie

2008-11-22T20:57:00.000-08:00

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?

2008-09-05T07:54:00.000-07:00

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?

2008-03-05T08:43:00.000-08:00

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

2008-02-13T19:29:00.000-08:00

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.

What else can I do for high blood pressure, I get enough exercise at work .........(warehouse/construction/daycare)

2007-11-02T17:49:00.000-07:00

When addressing patients for the first time or those that have been taking medicines for a while, I always ask, do you watch your diet and are you exercising. (For those with a large waist to hip ratio it's more of a rhetorical question.) But most will answer they are doing or have tried to do alot of exertion in the form of walking. Most will think of exercise as a form of walking. That is soooo 90's. Most of the articles on introducing exercise into a life style would safely say, try walking first. This was meant to be an intro for the first 6-8 weeks with the idea of progressing on if you didnt suffer and injury or drop of a heart attack. When I see a couple in jogging suits, both with grey hair smiling on a neighborhood trail, I think that is great, I can't wait till retirement! For a 30-40 year old, we should be thinking of "smoking" that speed walking couple but fact is that most of the construction workers, warehouse workers or moms chasing after 2 generations of children would run out of gas in 5 minutes. Remeber the tortois and the hare? The rabbit in this story enventually goes for angioplasty and gets placed on 2 medicines with a blood thinner. This is the threat I give to most of my 30-40 year/olds that are too busy to worry about a little blood pressure issue or slightly elevated cholesterol. True, its easier to take a pill than make a major lifestyle change and cut back on hours at work....but that way of thinking doesnt prepare for the next medical issue that comes then the next one after that. So like most people, someone comes in for a regular check up and without symptoms ends up on 2-3 medicines with medical problems and problem lists that would dwarf the 10 commandments. I always touch on the current life style of high pressure, fast food, poor family communication and lack of proper preventive medicine.

Just that title alone is a misnomer now a days. Preventive Medicine is supposed to be what primary care doctors are teaching in the community but most of the family practice docs, internists I know are finding medical problems and managing them but no one has time to teach exercise, diet, lifestyle modification. Its usually after the diagnosis and after the first or second pill that we highly suggest cutting back hours or sending to a dietician since the sugars are not responding to first line meds. We also have steps in place to check at intervals to find when the changes are going to occur but that is usually the only contact. "Ok Mr Smith, come back in a year and we'll check if the diabetes has begun. Or, keep on checking that blood pressure, 3 random times in a comfortable environment and when they all are above 120/80, I'll start you on something. I would like to develop a branch of medicine to establish nutrition based changes in addition to supplement design that would integrate into current hierarchy of modern medicine. Insurance would probably not pay for this but patients have already showed they would pay for it out of pocket. Imagine, after paying the 400-1000 per month for insurance just in case you get sick, paying even more money to prevent needing to use the insurance plan your dishing out monthly mortgage payments to. Medicine is so screwed up! Sorry, I am trying to redirect my anger and frustration into constructive development of something good for everyone.

Back to hypertension, exercise is supposed to be in the form of 20-30 minutes of any activity that would keep the heart rate in the 140-160 range,(personally I shoot for 160-170 but can only do this 1 time a week for 20 minutes, the rest of the week is standard 150 beats per minute for 60 minutes all preceded by yoga.) One is supposed to repeat this regime 5 times a week. For those on a limited timetable, more bang for the buck with yoga or tai chi. Most people have heard of yoga, a limited amount know tai chi but these two forms of exercise don't get the credit they need. I have had a handfull of patients able to get off medicines running, yoga and tai chi were the only ways. Some did it through fast aggressive weight loss but this was dietary directed with some form of cardio.

There are studies out that have reported stress control throughout the day with 10 minutes of yoga/meditation in the morning. Same with daily tai chi. Eastern philosophy will show if one is well "grounded" that the body is healthier and will repsond to daily stress and infection better. The chakras or meridias of the body communicate and flow better so to make the external layers of the body impenetrable to the environment. In more western terms, someone at peace will be harder to coax into a fight than someone already on the 3rd cup of coffee and running 10 minutes behind to get to the first appointment. This also can be achieved in the form of prayer. If we could all start the day like Bob Marley says; "don't worry"! we may do better in rush hour. Most people I would see in the office with high blood pressure would say "I just ran up a flight of steps for the appointment" or "I was stressed in the waiting room." My come back is if that is what happens in a waiting room, can you imagine what happens to you throughout the day several times a day with confrontations and problems? Bottom line is the heart and brain don't like the high pressure fronts placed on them and soon will suffer with blood vessel damage, muscle enlargement and ischemia. For the rare person that says I'm ready to die, I say the hospital will probably save your life and you will live, being cared for by your family, unable to work, with no medical insurance. Not a pretty picture but I believe it's the job of a doctor and a friend to help see the worst case scenario.

Standard cardio work outs are great. They give the all the organs, the heart in particular, great blood flow, more efficient muscle with millions of hard working mitochondria. When the heart is more efficient with its beating and contraction, it doesnt have to work as hard throughout the day. Lungs work better at extracting oxygen from air, liver gets blood flow so it can get rid of toxins and run it's multistep break down of things that would normally kill us. Even cells will be able to absorb glucose better and in many cases without the need of insulin when exercise excedes a certain level. The endorphin and enkephalin release post exercise is something only an avid exerciser can relate to. One of the reasons we get "bitten" by exercise. It is addictive due to the hypothalamus being stimulated by the hormone release. This would be the same spot morphine works on. Finally, during the 60-120 minutes after exercise, there is usually a blood pressure drop that occurs like after and orgasm. Yes, exercise can be fun. Something a doctor or therapist or personal trainer can do would be to figure which kind of exercise would be appealing enough to catch the attention of a particular individual. If that person can make it through the first 8-12 weeks without injury, they are probably on their way. The enthusiasm drops rapidly with failure to progress or injury. With the diversity of jobs and hours and facilities and paychecks, an advisor has to be well versed with what is available or at least what has worked for others in the same predicament.

From 5K's to rock climbing to martial arts to dance, find what fits the schedule, what is economically feasable and what sounds like fun. The "Saguil Approach" says working a 5 pound sledge hammer 8 hours a day is something a regular person can't do and I am impressed the muscles will tolerate that but that type of exercise is not what the heart considers relaxing and helpful, if anything, that form of exercise can induce a heart attack. Exercise should be prescribed, and I believe it should be paid for (hopefully soon a health savings account will allow this). Activity should be part of anyones rehab and treatment program for staying healthy. Even if you are already "active" and hypertension is found, you may still have to rethink what has to be done to avoid the pills or more urgently, "avoid the knife".

cut and paste to see the ACSM's stance on exercise:
http://www.acsm.org/AM/Template.cfm?Section=Home_Page&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=7764#Under_65

What do I look out for in getting MRSA infections?

2007-10-25T21:36:00.000-07:00

Here in Illinois (specifically DuPage county) there have been reports of MRSA. This acronym stands for methicillin resistant staphylococcus aureus. This bacteria has been around for about 30 years but wasn't so prevalent. When I was a resident working at West Suburban Hospital in Oak Park, we would occasionally get it in chronic ventilator patients. These unfortunate people would be on a ventilator for multiple reasons and of course on a ton of medicines. One note is they would most likely be immunocompromised due to multiple reasons.

There are medicines for MRSA but they are limited. Once a patient was found to be cultured with this bacteria, they would usually be placed in isolation for fear the visitors (nurses family and doctors) would spread the bacteria to other patients (kinda like TB in the 60's). Patients would stay in the hospital for multiple antibiotics till infection was showing improvement. Then they would usually be sent to a chronic care facility in the same restricted form of contact.

Now we are emperically treating patients with antibiotics (usually 2 or three at the same time) and sending them home hoping they clean up after themselves at home and work. Now as a review, the reason the staph became resistant was most likely due to overprescription of antibiotics a while back and now we are hitting every little bug that doesn't seem to respond to standard antibiotics with doubles and triples till the follow up visits with their docs and the cultures come back. God help us in the next few years when no antibiotic will touch certain strains of staph or any other bacteria due to this years' MRSA scare.

What people don't realize is that MRSA is a bacteria like any other. If the individual doesn't care for themselves properly in hand washing, showering and using soap and water on new cuts and scrapes, not sharing towels or clothing from others then any bacteria, not just MRSA, will cause an infection. That infection will need to be drained or blasted with antibiotics. Standard infections go away in 10 days, MRSA gets worse in 2-3 days. The front line tactic for MRSA still is the same for any infection: hygiene, rest, eat properly and exercise.

Poor hygiene, a stressed out body, poor nutrition, obesity, lack of exercise, poor sleep will lead to a body that can't fight the initial battle of infection. This is usually exposure to a bacteria and break down of the body barrier.

Skin is the first barrier: well hydrated and moisturized, nothing should get through. Unfortunately, nobody that works 8-10 hours a day likes to drink water since it results in having to urinate soon after. Not the best for a driver, outdoor worker, telephone operator, computer user. (I remember watching the movie "Pursuit of Happiness" with Will Smith playing a stock broker and he stated in the biography, he wouldn't put the phone down in the cradle or drink water cause it would give him an extra few cold calls at the end of the day.) I am also guilty of this, in seeing a day full of patients, I would not want to eat or drink since it may slow me down for 10-15 minutes and that would cost me one patient visit to put me behind and I would be playing catch-up for the entire day. (See my first blog on The Adventures of Dr Saguil for info on the 10 minute visit as paid for by medical insurance.)

Second barrier would be hydration. If well hydrated, the skin would react by producing thin protective oils to keep the outer layers tensile and unbroken. When dry, outer layers are parched, single cells are separated from each other and flaking occurs which further hampers pore function by blocking the skin pore from making sweat and oil to trap bacteria and prevent further deeper invasion. Being well hydrated also produces a very effective vascular volume. More blood to the skin brings more white blood cells to fight invading organism.

Third barrier would be a properly functioning white blood cells. Tobacco, poor nutrition, lack of multivitamins and supplements, or uncontrolled medical disease states (like diabetes) will hamper the way white blood cells work. Lets consider white blood cells to be policemen. Even if we have a large police force in a city, if they don't know how to arrest or pursue, a crime will still occur. Considering that 50% or more of the US population is overweight and eating poorly, this alone will decrease body defense. Throw tobacco, alcohol, high fat diets in the mix and one is asking for an infection to invade.

Forth barrier is more of what doctors are doing and what patients are demanding. Many patients go in to see the doc just for a diagnosis. Many aren't satisfied and also want a prescription medicine. This is especially in the pediatric population. Most parents feel better when they leave having an antibiotic for the fever and cough even if the infection is just a virus and will go away on it's own. Remember, more antibiotics cause more drug resistant bacteria in the community.

To piggyback on the forth barrier, most docs don't suggest acidophyllus use during the antibiotic 5-10 days. All antibiotics kill indiscriminantly. All those colonies in the throat or chest or urine or sinus' will die for sure. Unfortunately, the good ones in the colon, stomach, small intestine, vagina and skin also die. Our "normal flora" found in the GI tract are there to help with digestion and function. When they are all killed, only the worst and strongest bacteria and fungus will remain. Let's consider the normal flora in the colon being an average classroom of highschool kids. When all the "nice" smart hard working kids are kicked out of school, you are left with the truant, delinquent tough streetwise kids. The resultant class is totally different...get it? So after the "nice" kids are gone, if a large influx of some other nice kids come into school, the bad guys are usually kept quiet just by outnumbering force, and the class continues uninterrupted. This is where probiotics come in handy. Two tablespoonfuls of liquid probiotic or one three capsules of acidopyhyllus/bifido will reboost the stomach, small intesting and colon with good flora. (Usually given 2 hours after the antibiotic is dosed)

So in summary, The Saguil Approach is to do what mom always harped on. Wash your hands, eat vegetables, take your vitamins and go to sleep on time. Translated; good hygiene, good nutrition, decreasing stressors, staying hydrated, taking supplements/probiotics, and avoiding and controlling disease issues. Allow no bacteria to get through the barriers and you won't have to worry about MRSA. Of course getting professional opinions when something starts to look unusual would be important if it has already invaded but most people have the potential to fight off infection without antibiotics. Personally, I hate antibiotics, the last time I took one for a self diagnosed sinus infection, I got Pseudomebranous colitis after one pill of zithromax and remember thinking to myself.....this has got to be a ruptured appendix as I tried my hardest to stick acupunture needles everywhere I could to treat nastiest pain in my life. That was about 5 years ago and haven't used anything since while living through Chicago's winters and hundreds of patient encounters with infections of their own. Although I do use some herbals to boost immunity...next blog. (5 bucks to anyone who finds I don't wash with soap or use antiseptic gel after I examine them!)

My allergy medicines aren't working anymore

2007-10-12T04:27:00.000-07:00

I was walking through my favorite store that I will keep anonymous, they sell a wide variety or supplements, cooked and whole food. Was talking to a rep for one of the companies that makes omega 3 and couldn't help but notice he had a very nasal sounding voice, a reddish hue to the center of his face and most of all he was set up so the aromatherapy and incense was directly across the aisle from him. I did spend some time inquiring about his product and he answered well, (I usually like to listen intently on how a rep sells his/her product and what basic knowledge they have before I tell them I am a physician and that I use herbal products for myself and my patients). All during this time I try not to focus on his nose but my mind automatically pictures me checking his nostrils in the office with a nasal speculum.......(sometimes this triggered response I have to ordinary situations scares me). I will be talking to someone at a party or chance meeting and while conversing, my mind wanders about a working diagnosis for what I see before me. Anyway, after he is finished and gives me some samples and a dvd (love freebies!) I point to the elderberry in my basket and say to him, "you may need some of this for the rest of the week". He acknowledges and states he is already on Zyrtec (an antihistamine that some how states it is the best thing for cats, cigarette smoke and plant allergie;, although it isn't the substance exposed to, but more the person that is having the histamine reaction we must try to control) and nasonex (A steroid nasal spray that controls local response in the nose only). He had some cat fur on his sweater and after I asked, wouldn't you guess....he has 3 cats that supposedly didnt go in his room at night. Wouldn't that be great if pet dander, pollen and dust mites would stay in areas of the house where they are supposed to stay! When I was in practice, patients with nasal symptoms who had all the classic signs of allergies would usually tell me they were tested and the allergist stated they have no problems with cats, dogs or milk. I still believe that several small allergens all together at the same time will still have the body act in the same way as one big exposure to a single allergen. So with this person, same theory in the "Saguil Approach" goes; if placed on a medicine, it would be as a temporary measure at best. These folks are placed on meds and not told to do much with the environment around them or their diet. Just like echinacea is supposed to be used for short term only, the perscription medicines should be used short term only.
Other herbal medicines are stinging nettles (a favorite or Dr Weil) and butterbur. If things progress over the allergy line and into the infection stage.....all the above continue and then I like andrographis (paniculata), garlic, quercetin, mushroom extract(reishi, cordyceps, shitake) elderberry is a great alternative for kids. Many times in the ER we see kids that are sick but all tests and evaluations yeild nothing to treat so we say go home and wait....well this is where I think alternative medicine excels.

For extinguishing allergic response, there are the typical shots we give to desensitize the patients over a course of a few months. Essentially giving the patients micro amounts of what they are allergic to every week to have the white blood cells(eosinophils) take a little at a time and hopefully learn that the compound is not irritating. Increasing the amount every few weeks will "desensitize" the patient after a while. Immunologists say they have great response but I guess I see a different portion of the population, most of the "average joes" that come into the office are obviously sick and allergic and still getting shots. (Sometimes I see patients that have been getting shots for years!) Usually, these kids have been taken off gluten, casein and wheat already-god bless those parents for being so tolerant to the problem. I have found homeopathy is great at allergies especially since their concept is based on slow exposure to a substance in order to change an eventual reaction the body manifests.

In summary, "Saguil Approach"-
take care of the environment around you
change the pets diet (possibly to human grade meat)
change the pet
vacuum and dust sunday and thursday
allergen central air filter (3M)
alot of fluid for you
spray the nose with saline douche 3-4 times a day
echinacea or stinging nettels- 1 month before allergy season
zyrtec, clarinex, claritin, allegra, asteline if above doesnt work
avoid direct contact with sick people -hand shakes,hugs,kisses,pens
cut down animal protein, no dairy (but take a calcium/vit d3 pill)
add garlic and ginger
elderberry, andrographis, quercetin, mushroom extract
homeopathy drops to desensitize, doctor to look into leaky gut
allergist to test and consider shots and try to avoid long term steroid!

oh...puffs plus or tissue with moisturizer added to prevent abrasion to the nose.

Should I be on a certain diet when my joint is so inflammed?

2007-10-05T14:56:00.001-07:00

I like the way Andrew Weil makes choices for dietary restrictions in those with inflammation. This is usually asked of me when a patient is going through a sprain or strain of a body part and I am putting them on the trifecta of:

1 an antiinflammatory
2 a muscle relaxant
3 a pain reducer

We can sometimes get by without this "cocktail" but people present in extremes and the discofort is agonizing to the point of the patient and family being desperate for immediate change. I had mentioned in the post on "which protein powder is good for gaining muscle" that white willow bark, turmeric, boswelia and ginger are good for antiinflamatory properties. I have tried New Chapter's Zyflamend and Natures Sunshine's IF relief. Both had great results with nostomach upset. There should be limitations to duration used and in some with true joint disease a compound with glucosamine sulfate would also be useful. (As an aside, I was using glucoasamine in the mid 90's with my patients using European studies as a basis for trying it. Also my older patients were developing ulcers and reflux with typical NSAIDs used for joint arthritis. Only a few years later did I see some of the orthopedic surgeons trying the same for teh arthritic patients we sent them. This was one or two "pods" in Wheaton Illinois. You can imagine the thrill I had when Whole Foods was built behind my office and this was the first I heard of this concept.)

I will usually involve my patients immediately in some form of movement (physical therapy, yoga, tai chi) and a diet. The diet is more of a restriction diet. The American culture is based on fast cars, fast money, fast food and built into this is a very poorly calculated diet rich in milk, sweetners, fat and salt. Everything to make you release serotonin and feel great after eating. The normal post prandial wave or parasmpathetic hormone release that occurs after a meal is increased with the ingestion of simple carbs that have a very high glycemic index and fill the blood stream with immediate glucose for that tsunami of hormone to be released from the gut and stimulate the brain cells. Well, the average american is eating to set him or herself up for inflammation whether in the form of poor tolerance to exertion and resultant muscle soreness or that deadly inflammatory response that occurs in the blood vessels laden with cholesterol plaques called CAD (coronary artery disease).

"The Saguil Approach" to an antiinflammatory diet:

No dairy
Change animal protein to plant protein-switch from red fatty meats to soybean, tofu soymilk or lean cuts
Avoid processed meats (nitrites cause inflammation)
Multiple colors of fruits and veggies daily(shoot for 5)-(Berries are great)
Start cooking with ginger and turmeric (try indian dishes)
Start preparing cold water fish dishes (SLASH-M see omega 3 post in the herbal411review blog)
...or take omega 3 fish oil
Use extra virgin olive oil as the main fat and eliminate anything that is deep fried containing transfatty acids.
Avoid Nightshade family?
Increasing fluid intake is mandatory

Reinforcement of goals achieved if very useful. The person suffering from acute or chronic inflammation has 24 hours of pain they experience so any applause that they have made it through to a first or second goal is helpful. When under duress, concentration is lost and sometimes the one in pain forgets they are actually able to move a joint now or walk with less limp. Our ER is built on determining if the treatment is successful by lowering the pain scale from 10/10 to a lower number. Problem with this mentality is a patient will keep on saying it's a 10 until mental faculties and so distorted that either they are asleep or slurring their speech.(oh but they are still a 10/10 because the pain is still in the same place-remember, we didnt fix the inflammation, we only dulled the brains' interpretation of it so even if they are now drunk, the joint or body part still aint moving and is still as hell.) Occasionally we do win and that patient states the headache or back pain is better but these are also the patients that are moving the extremity and pumping the muscle to the previously guarded area....maybe more blood flow, less lactic acid or just the golgi tendon organs in the muscle are getting a massage?

So next time the doc whips out a script of three different medicines for that pain.....try adding this diet to the next 1-2 weeks and see if it gets better faster.....maybe you might like the diet and save your heart too!

How do I carb up for a race?

2007-10-05T08:29:00.000-07:00

When I was the team physician for University of Central Florida,the trainers for the endurance sports usually came to the weekly clinic with one or two athletes that were eating "weird" before a competition. Most notorious were the mens soccer player. Great group of guys and excellent training staff but some of the guys were scholarship athletes from different countries so not only was there a language barrier, there was also a difference in food preferences. The soccer team as an example had a very deep bench and coach could call on substitutes frequently so top players didn't "hit the wall". (a term used for running out of energy during a work out or competition). Ask any distance runner or cardio athlete and they can tell you one time they just had no more gas to continue and just felt lousywith huge performance losses. Most non-cardio aggressive sports will be able to rest and conserve energy so as not to "bonk out".

When I asked about how these athletes would prepare for a saturday match, Greg (the mens soccer trainer) would respond they hit the cafeteria and try to choose high carb foods for the dinner friday night. This is basicly correct but it can be tweeked. I like the old way which was draining down 2-3 days before the event with a low carb diet (20% of total diet being carbs) thendoinga high aerobic exercise 1-2 days before and loading with a high carb diet the day before the event when the work out is light. This is the way it was done in my day when John Travolta did the Saturday Night Fever thing (the 70's). Newer versions cameout in the time of PearlJam (the 80's) where an athlete didnt have to dwindle glycogen stores down before the load and just started to load with a gentler amount of carbs in the diet 3 days or so before the event. (70% carbs) Being an herbalist, I always like the concept of clearing out the liver before a big event anyway. (Those unseen toxins and free radicals do accumulate somewhere....but thats another post!)

There were studies to prove that athletes did run out of glycogen stores in the liver by end of the 1st half. Muscle biopsies were done on the athlete begining midway and at the end of a soccer match (who on earth would allow someone to poke a needle into a calf muscle and study tissue fibers while playing soccer...I guess thats the payback for paying a scholarship). Results showed glycogen stores were close to 90% depleted by second half. That leaves an entire half game played with no energy stores. Most division I athletes can continue to execute technique but overall prefomance will suffer. Remember Micheal Jordan returning to his first game after retiring the 1st time and he still had technique but younger players were running all over him and stealing balls. Of two equally matched teams in talent, the one with higher nutrition levels in their player will be able to take advantage of the players on the other team running out of gas. In the real world of 50 hour work weeks, child care and limited time to compete, we dont often compete with others but performance decreases will be seen in fatigue and aches lasting the days after a routine work out or work performance and concentration being effected days following a hard work out. Worse case is that we may open ourselves to infection due to the immune system being stressed from excessive glycogen store depleation and poor rest when we need protection from the bacteria our kids bring home from school. (Same concept as a diabetic being more at risk for infection, white blood cells are supposed to fight and gobble up bacteria but if the glucose molecule cant get into the WBC for energy creation, it wont function properly to track and kill bacteria.)

The real world approach to carb loading still exists for the division I II or III athlete, regarding the specific types of carbs to go to the store and look for, I have been requested to write a blog on spcific shopping.....keep posted on a new blog! If you are not in competition for a 5K, triathalon, marathon or
endurance sport, still consider hitting the high carb intake within 2 hours of an aggressive work out to at least prepare for the rebuilding phase of muscle or the next work out. Many of the average joes that consult me are working out to gain muscle and lose weight and dont consider themselves athletes but I warn you that there will still be a bonk out or hit the wall point where health will suffer, it just may not be as sudden as the competitive athlete. The two hour rule is the golden hour as I call it when muscle membrane and glyconeogenesis in the liver is peaked to form high stores. After that the hormones that are circulating in the body arent as keen on taking carbs/glucose into the liver or muscle cell and convert to glycogen. (Think of glucose floating in the blood stream as electricity from an outlet and electrical cord; glycogen as stored energy in a battery.) In a game, theres no electrical outlet to connect to and we rely on the battery. On the bench we can "plug in with gatorade or power gel". -Not necessarily the best but most US schools are sponsored by gatorade. The proper ratio of carb to protein ratio is 3carbs to 1 protein within 15 min and up to 2 hours. Simple carbs are better, those with a higher glycemic index, since they get absorbed rapidly. Here is a nice table from www.gssi.com:

GLYCEMIC INDEXES OF COMMON FOODS

Breads & Grains
waffle - 76
doughnut - 76
bagel - 72
wheat bread, white - 70
bread, whole wheat - 69
cornmeal - 68
bran muffin - 60
rice, white - 56
rice, instant - 91
rice, brown - 55
bulgur - 48
spaghetti, white - 41
whole wheat - 37
wheat kernels - 41
barley - 25

Cereals
Rice Krispies - 82
Grape Nuts Flakes - 80
corn Flakes - 77
Cheerios - 74
shredded wheat - 69
Grape Nuts 67
Life - 66
oatmeal - 61
All Bran - 42
Fruits
watermelon - 72
pineapple - 66
raisins - 64
banana - 53
grapes - 52
orange - 43
pear - 36
apple - 36

Starchy Vegetables
potatoes, baked - 83
potatoes, instant - 83
potatoes, mashed - 73
carrots - 71
sweet potatoes - 54
green peas - 48

Legumes
baked beans - 48
chick peas - 33
butter beans - 31
lentils - 29
kidney beans - 27
soy beans - 18

Dairy
ice cream - 61
yogurt, sweetened - 33
milk, full fat - 27
milk, skim - 32

Snacks
rice cakes - 82
jelly beans - 80
graham crackers - 74
corn chips - 73
life savers - 70
angel food cake - 67
wheat crackers - 67
popcorn - 55
oatmeal cookies - 55
potato chips - 54
chocolate - 49
banana cake - 47
peanuts - 14

Sugars
honey - 73
sucrose - 65
lactose - 46
fructose - 23

Beverages
soft drinks - 68
orange juice - 57
apple juice - 41

Foods listed from highest to lowest glycemic index within category. Glycemic index was calculated using glucose as the reference with GI of 100. Modified from Foster-Powell and Brand Miller (1995).

So the "Saguil Approach" is if you are in competion for a moderate cardiovascular event increase exercise intensity 1-3 days before the event, decrease carb intake 2-3 days before the event, load with high G.I. foods day before the event. Replenish with high glycemic foods, gels or drinks during the event. Finally, if you just work out but intend to "max out" every 4-6weeks, try to keep a balanced diet at all times, intake a 4/1 ratio of carb to protein within 2 hours of finishing the work out and for the love of Pete, don't be spending on expensive protein mixes or weight gain/slim down powders when not even maintaining a proper diet, sleep regime or vitamin supplement schedule. If you try to cut corners, you may not hit the wall or bonk out as aggressively as my D-I students but at one point you will get hurt or sick and plateau. (Email me or see an approved american dietetic association nutritionist or dietician). Exercise safely and have fun!

Which protein powder is good for gaining muscle?

2007-10-05T08:27:00.001-07:00

Since I see have extra training in sportsmedicine, I would usually get this question thrown to me at the end of a physical or as I am about to discharge a patient from an injury we were working on. I come back with asking what weekly calorie intake is and the answer is a grab at the chin and a stare to the heavens. Usually the question comes from a 20-30 year old that is breaking into weight training and paying a trainer or someone with knowledge on exercise. The common problem I find is that most teen-to-20+ year olds will still be eating poorly. I attribute this to a learned behavior from high school. Most teens don't eat breakfast. (I remember my nephew forcefully stating to his parents "why would I want to wake up early just to eat breakfast?") Good question for his age, he probalby gets by with the poor nutrition and can function the whole day with little to no good calorie intake. Most people just "get by".

Building a body like Mr. Olympia, or being able to train to win a triathlon will take more than a cup of coffee for breakfast, sandwich for lunch and plateful of something for dinner. When my 20-30 year olds take massive protein mixes that cost a lot but skimp on basic meals....it's a waste. I always start out with suggesting a good multivitamin with multi B, calcium,D, zinc,selenium biotin and possibly coQ10. Add this to 4-5 meals a day to total about 3500 calories daily with 8 hours of sleep and a month to two month time table. A nice herbal antiinflammatory would help but thats over stepping the first suggestion. (The "saguil approach" suggests easy goals that are attainable over a short time with frequent checking in) Once they stick to the basics and 1-2 months has passed, I would for- sure suggest changing the work out schedule and add an herbal antiinflammatory like tumeric, white willow bark or boswelia. Sometimes a multi-ginseng, cordyceps combo capsule would help push the energy level for those stepping up the intensity of their exercise. The change would be power lifting movements for those trying to gain size; cardio or interval training for those trying to get cut, lose weight or get the heart tuned up and off a medication or two. I then would get start breaking down the amount of proteins, carbs and fats in a 2 week diet diary. I usually wait 2 months because I find good foundations have to be attained before I have them buy expensive protein supplements, energy bars or even talk about old fashion carb loading.

I always liked the way Mr Miagi would pace Daniel-san to do basic chores around the dojo before he would teach martial arts techniques. (Obviously trying to get Daniel to learn discipline and respect for power). Some of my well weathered patient athletes are already into proper health, nutrition and rest so when they ask about supplements, I do go straight for names, companies, brands and amounts. Bottom line is that many over the counter companies that advertise in muscle mags, runners world, triathlete boast many benefits to taking their supplements but they all fall under food supplements and the FDA has no control over the quality of what they place on the shelves. Something to look for would be if the company produces pharmaceutical grade supplements. Those that are bioavailable in the bloodstream at 90+% within 1-3 hours of digesting. Having samples tested by an independant lab would also add credence to company quality assurance. I also give the average athlete the example that a Division I NCAA college athlete on scholarship would usually take a season to improve on a technique, gain strength or shorten a time. This is essentially an olympic level athlete I am describing so if my average patient is wanting to see results of size increase in 2 months, I reset their thinking and give them more attainable goals.

In summary, 3000-3500 calories daily, 7-8 hours of sleep per night, multivitamin as stated above, flexibility routine daily, and 2 month goals. A risk factor review is good, hold the caffeine, tobacco, stress, and keep the chatter down in the gym. (I find too much conversation slows a work out down and before you know it, workouts are 2 hours not including travel). This kind of scheduling is a set up for failure. [To explain, average person works 40-50 hours a week, 10 hours a day, one hour of travel, 6 hours of sleep, 2-3 hours of chores and relaxation.] Now add two hours daily of exercise not including travel and that fills up the day. One hour would be better and less likely to end up in frustration and failure when winter holiday comes and days shorten with more responsibility that time of the year. "Fancy" supplements for exercise are whey protein, spirulina, L-arginine and cordyceps.

Before signing off, steroids will always be taboo but alot of people will try them just the same. People have to be made aware of the side effects to these short cuts not to mention getting arrested. In my "heyday" when I won Mr Natural New Jersey and Mr Novice East Coast, I competed against guys who did "roids" and I could see how fast these guys blew up and how synthetic they looked when in competition. I wonder how many had died, (one for sure since 1982 I saw in a local paper), many more I'm sure with other problems. From what I understand, "gym rats" are trying concoctions of herbs even to the point of using a milk thistle to clean out the liver between herbs. Unfortunately, there are too many underground body building pushers and just a couple of people who do what I do. That's ok, if I can change one person at a time, that's plenty.

How can I loose weight in 2 weeks for a wedding?

2007-10-05T08:22:00.000-07:00

Fast dieting usually leads to fast loss in a week or so but then fast plateau in the loss thereafter. It is thought in most non-medical circles is mostly loss in "water" weight. Many things will happen hormonally when the body is faced with an acute decrease in circulation glucose levels. Much of the body response is due to release of glucagon by the pancreas leading to the breakdown of glycogen in the liver. This goes fast and within a day, if exercise in also started, the action can dwindle stores to very basal levels. If the body continues this path, fat stores are call on to contribute to the glucose production. The built in mechanism to stimulate the body to hunt for more glucose stores is the symptom of craving. The hypothalamus is stimulated by release of hormones and also from the low glucose stores. This is sometimes noticed in "carb hunting" after drastic low-carb diets.
In theory, if the brain can be fooled into accepting the low glucose concentrations in the blood, the short term fasting will be easier to tolerate. Supposedly, the manufacturers of Hoodia say it works by fooling the hypothalamus (though not enough evidence for effectiveness). The drug Redux had also been studied to release serotonin thus depressing appetite and anxiety. It also was reported to cause primary pulmonary hypertension and nerve damage. Much of the same problem occurred with fenfen and Ma Huang (ephedra) which was pulled off US shelves.

More natural ways to fool the brain indirectly would be to increase the fullness in the digestive tract. Water, fiber, frequent smaller meals. Some have tried aroma therapy to sooth the brain when the hypothalamus is prompting the "hunt" to start. Another trick is to exercise which releases a strong fight or flight stimulus. The sympathetic hormones command more response from the body than the parasymathetic hormones so "anger" wins over "eating". The obvious answer is that it isn't healthy to do fast bursts of weight loss. If it must be done over a short term period, consider calories in and calories burned. Use exercise and wise food choices. Keep schedules busy (don't mistake hunger for boredom) and when hunger does come up, don't have high calorie snacks around to choose from, (junk food, simple carbs, candy). Be weary of any supplements that state appetite suppression. Since the FDA doesn't regulate labeling, three of four bottles on the shelf probably won't even have the ingredient at high enough doses in them. Many of the effects from the new cans of energy/weight loss drinks are from the caffeine component, (again stimulating the fight or flight hormone release of epinephrine and norepinephrin) which elevate blood pressure and decrease sleep.

Here is an FDA post of the recall of Fenfen for heart valve problems....http://www.fda.gov/CDER/news/phen/fenphenpr81597.htm

The "Saguil Approach" is to do things in moderation with easy goals every 4-6weeks. The attention span for an average individual is 20minutes to read one of these blogs and I believe 4-6 weeks to perform a specific routine in exercise, after that, muscle develops engrams to memorize routines and it's not asmuch of a stress anymore thus body gets used to the progam and no further gains noted.....the typical plateau people talk about....(that I term sling shot period since re-adjusting the routine, diet or time of work out will "slingshot" you to the next level.) Plateau is such a terminal decription. Diet safely and be patient...push the cardio because that is essentially the only way to burn up all stored glycogen and start to have the body call on adipose tissue for energy. Burn adipose tissue and fat depots will shrink.