The Little Prepper Doc

The Duck Ages of Folk Medicine: The Good, the Bad, and the Quacks

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 05 Nov 2011 16:15:00 +0000

There I was minding my own business, doing my talk show host thing with my guest wonderful John Milandred, and then the cruelty happened... The technological universe decided to chew up my broadcast and spit it out like a leftover burrito. It was almost as if the botnet of the evil underworld attacked our stream. (Image refers to the book "Slow Death by Rubber Duck" that can be found on http://slowdeathbyrubberduck.com/)

Fortunately, after the whining, belly aching, and beating the computer like a red-headed stepchild in an alien family, my show was saved by Ed Corcoran, the founder of Survivalist Magazine, whom stepped in like a technology superhero. He jumped on the air, covering the broadcast silence with his talk show host expertise. (Ed is the host of the exceptionally rated The Complete Survivalist Show which airs 7 pm to 8:30 pm central time on KPRN-DB the Prepper Podcast Radio Network. You can find out more information on this tech hero on http://www.prepperpodcast.com/Host-Bios.php.)

Anyway enough about the technology gliches and hero talk show hosts, I've got a lot of folk medicine to talk about. Due to the infraction of the technology demons, we lost a bit of valuable time on air and I wasn't able to cover the amount of folk remedies that I had hoped to. (Granted, it was fun having both John and Ed on at the same time, bashing each other like two conquistadors fighting over the prize gold: my audience. ;). My listeners are the best.)

Before I begin describing the best and worst of folk medicine, I'm going to take a tiny detour to discuss the history of advances in medicine.

The History of Medical Stubborn Blindness

I know what you're thinking: "A history lesson? Nooooo!" Oh, come on. You know you love history. Besides, this is all about how medical professionals can be so pigheaded and dumb, when they think they know everything. Everyone loves a good medical community bashing. I'm a doctor and I eagerly get out the sticks looking for the medical pinnata. ;)

Just so you know as if you haven't already guessed, there is a stubborn tendancy within the medical establishment to ridicule its own members if they present ideas different from the mainstream. Oh yeah, its all about the jealousy. Because a lot of those scorned by the medical community tend to be the fathers of true medical advances. Yep, the green-eyed monster strikes again.

A brilliant physiologist named William Harvey was one of the most prominent men ridiculed in this manner. He was the personal physician to King james I. Yep, they definitely hated him. In 1628, he discovered the true circulation of blood. Before him, all medical beliefs on the body's blood circulation came from a dinosaur physician named Claudius Galen (birth 129 AD to 199 AD), whom argued that arteries were just to cool the blood and the heart was the major heat source of which the lungs "fanned" it and discharged "vapors" through the skin. Yeah, there you have it: the heart of our home is the microwave, according to pre-Harvey medicine. This ideology stated that there were two separate blood circulations: the Natural System being the venous blood flow and the Spirit System which was the arterial.

Harvey argued that the flow of blood traveled through the body as if in a circuit, connecting both the venous and arterial systems. For this discovery, he was humiliated and mocked. And it wasn't until after his death, that the medical community of the time finally accepted his discovery as fact.

On my show last night, we discussed the situation surrounding Hungarian-Austrian physician, Dr. Ignaz Semmelwiess (1818-1865). During his lifetime, upwards of 20 to 30% of women and children died during and shortly after childbirth. This was believed to be due to something called "childbed fever" or "puerperal fever," which led to septicemia and death. One of the members of the Clostridium family of bacteria is often accredited with this condition.

He discovered that his medical students that came directly from performing autopsies on mothers that died of puerperal fever to deliver babies from healthly mothers without washing their hands, had higher rates of death among their patients.

So Dr. Semmelweiss argued that doctors should wash their hands between patients. He even went so far as to develop a chlorine wash: a little rough for today's standards of antiseptic handwashes, but still effective. The medical community went for a WWF smackdown on his reputation, ridiculing him to the point of destruction. Heaven forbid that doctors should have to wash their hands! The punk beastards drove Dr. Semmelweiss to a mental breakdown where he died in an insane asylum. All because they were stubborn and didn't want to change what they felt was the standard of medical care. Only years after he died did Dr. Semmelweiss's physician hand hygeine become recognized as an essential advancement in medicine.

The use of nitric oxide in dental work and the use of vitamins in the treatment of diseases and the prevetion of diseases were also met with the same vehement disgust by men too stubborn to look past their own noses.

The moral of the story: Medical advances are always ridiculed by those who are too stupid to realize that something different might just be worth looking into.

Most of the folk remedies that are scientifically proven are still seen as subjects of ridicule by many in the medical community. Granted, there are many old folk remedy wives' tales that should remain just tales, but the remedies that actually work are often lumped in with the quackery as though the modern medical community can't get rid of the stubbornness of their predecessors. Thus the cycle of persecution and unwillingness to investigate different avenues of medicine perpetuates.

Folk Medicine: Fact, Fiction, and Flat Out Quackery

Okay, I know, I should start with the factual evidence behind many folk remedies, but I so have to tell you about some of the funnest quackeries I have ever heard of. I know. I know. You want to refer me to the history of stubborn medical people that I just wrote.... but seriously, you are going to love these ones.

Goose poop for treatment of pimples. I discussed this one on the air. Mmmm mmm mmm! Now, that's a facial mask that brings a whole new meaning to "getting to the bottom of the problem." Fact, pimples are caused by bacteria and oil glands that like to have a party together. Second fact, poop is full of bacteria, most of which is extremely harmful.

This idea comes from the age old wives' tale that dog dung was a good treatment for inflammation and wounds. Yep, some brilliant person in the dark ages decided that rolling around in dog feces would cure everything from baldness to the plague. Another good reason why those times were called the dark ages.

I'm beginning to think that it all started like this:
A nobleman stepped in a big pile of steaming dog poo.

A noblewoman whom he was trying to court sniffed the air and asked, "What foul smell is thus?"

Nobleman lies, as do all those trying to score a chick: "'Tis... uh... um... my medicine for knight's foot. All that jousting needs a... ah... potent medicine, milady." (Yeah, potent as in poo. And thus started the dog dung fad.)

Clipping toenails for a year will cure asthma. This one was perpetuated in the 1800s. This might come from "the toenail bone is connected to the lung bone." LOL. Okay, for the record there is no toenail bone and no lung bone, and contrary to popular belief they are not connected that directly as for toenail clipping to treat asthma.

Biting into a live black or rattlesnake will ensure good teeth and prevent toothache. I love that one. I wonder how much the live snake will appreciate that "remedy." I think it is self-explanatory as to why it fits into the quackery realm.

A sty in the eye can be cured by rubbing it with a live black cat's tail. Now, we got to appreciate the live black animals motif in these folk fakeries. Do you think the cat will be obliging to this quackery?

Okay, enough of the fun quackeries. Now onto the folk remedies that actually work.

Prickly-ash tree bark for oral analgesic. The Prickly-ash tree, also called Zanthoxylum americanum, is a shrub/tree that bears throny branches, aromatic leaves, and a seriously kicking analgesic bark.

As John Milandred said on the Little Prepper Doc show, Native Americans have been using prickly-ash tree bark for toothaches, stomach aches, and inflammation. John indicated that taking an inch of the bark and popping the bitter crud into your mouth produces a numbing effect greater than that of novocaine.

The science behind this is that the bark contains active chemicals such as tannins, ligins, coumarins, and alkaloids. Tannins for example have been proven in studies to have antiinflammatory, mild analgesic, antibacterial, and antiviral properties. Ash tree bark is contraindicated in pregrancy, nursing mothers, and those that have intestinal or stomach ulcers.

A good recipe for prickly-ash tree bark tea is to simmer 1 to 2 tsps (or 5 to 10 grams) of crushed bark in water for 15 minutes or to chew the bark uncooked to relieve tooth pain.

Maggots as a natural form of debridement. The little disgusting wormy fly larvae are the best natural form of debridement in existence. The nasty little critters eat only dead and diseased tissue leaving the healthy living tissue behind. A good story of this was a homeless man came into the ER for foot pain. The doctor looked down at his foot and saw a moving boot of squirming maggots. After almost losing his lunch, the doctor bravely sends in the nurses to clean off the man's leg and give him a good shower. Once the maggots were removed, the tissue left behind on the foot was clean and healthy. The maggots had done their work, preventing gangrene from setting in.

Poultices. The variations in poultices is as broad as an elephant's boxer shorts. Hot oatmeal poultice was used to draw foreign objects out of the skin that are unobtainable by tweezers. Mustard chest poultice is a combination of crushed mustard seed and water (enough to make a paste) with a 4 to 1 parts flour. Place it on the chest of a respiratory patient, changing it every six hours. It has been shown to help in the lymphatic flow of fluid out of the lungs.

Meat tenderizer poultice is a combination of meat tenderizer powder and spit or water to make a paste that is used for sting relief in bee stings. The enzymes in the meat tenderizer breakdown the proteins in bee and wasp stings. Ed Corcoran indicated that honey also can be used for sting relief.

Onions to avoid viral illnesses. One of the interesting findings was that the onion farmers that would sleep a bag of onions next to their beds never came down with the Spanish influenza. Instead, the virus was found in the onions that they slept with. Mmmm.... some people prefer wives, these guys preferred onions. On a more serious note, onions were known for their "drawing power" in folk medicine. In actuality, onions have superb air filtration properties, which collect airborne viral particles, pulling them from the air.

Living the pioneer life. John Milandred, the founder of Pioneer Living, actually practices what he preaches. He lives in a pioneer-style environment without the "technological essentials" of microwaves, plastics, and gas stoves that the rest of us can't live without. He also organically grows his own fruits and vegetables, as well as eats pure and healthy foods. Some people call him an alien because he never gets sick. He has no idea of what the flu is like because he has never had it, nor has he ever taken any vaccinations for it either.

On the opposite hand, environmental researchers Rick Smith, who is the executive director of Environmental Defense in Canada, and Bruce Lourie who is the President of the Ivery Foundation have proven that living the modern-day life might not be so healthy.

In their book, Slow Death By Rubber Duck, Smith and Lourie spend four-days in a "technology-rich" environment eating only foods microwaved in plastic containers, out of cans, and cooked in teflon-coated pans, living on flame-retardant coated furnishings, and enjoying the comforts of synthetic carpets. Prior to their four-day excursion into a surburban condo, the two men had their blood and urine levels of 7 different toxic chemicals measured for baseline. After the four-days, they were measured again to see if the levels of toxins had increased. Sure enough they had tripled and in the case of one chemical known as triclosan, it had multiplied by nearly 2,900.

After the 24-hours of the tuna-eating mercury test, Bruce Lourie started experiencing early symptoms of mercury toxicity such as severe irritability, loss of memory, and anxiety. According to their book, he didn't remember much of that day, which is charcteristic of mercury poisoning. Also his blood results revealed that his blood mercury level had increased far above the "safe" zone indicated by the United States Environmental Protection Agency.

So there is something to be said about the folk remedy of natural and organic living.

It looks like it is time for me to go.

If you didn't get a chance to listen to the Little Prepper Doc show live on Friday, Nov 4th 2011, you can still listen to it on http://www.prepperpodcast.com/Prepper-Doc-Show.php.

Thank you and TTFN.

The 1st Little Prepper Doc Show!

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 29 Oct 2011 02:13:00 +0000

Hello world! Okay, tonight was my first live broadcast on KPRN-DB, the Prepper Podcast Radio Network (http://www.prepperpodcast.com/Prepper-Doc-Show.php).

Yes, it was nerve racking. Seriously nerve racking as if you look up to see a big smelly sumo wrestler was about to squash your head with his bare-naked bum and you have only two seconds to get out of the way.

I was so nervous that I even made a mistake in my speech: I meant to say Coccidiodomycosis (or also called, Coccidiodomycoses) which is a fungus that caused lung infections in California after the earthquake. Instead I said Cryptosporidium which is a protozoan that causes diarrhea. LOL.

Blast those $5000 words! There are so many of them that when you break out into a cold sweat from nerves they start stumbling over each other out of your mouth. Total word salad. Except my word salad was like adding tomatoes to a fruit salad and then adding a spoonful of pepper: it just should never happen.

Anyway, it was fun broadcasting live. From now on, I will have at least one post per show to give further information about the material mentioned in the Little Prepper Doc show.

For those of you that don't know about the Little Prepper Doc show, it runs similar to this blog talking about the ins and outs of preparedness medicine. Next week I will be talking about folk remedies: Do they work and how they work. Please Stay tuned. The Little Prepper Doc show runs Friday nights at 8pm central time.

If you have any questions that you want answered on the show or subjects that you want to hear more about, please email them to disaster_medicine@yahoo.com with "Little Prepper Doc" in the subject line.

Thanks to all of you that listened to my broadcast today. If you missed it, you can download it at http://www.prepperpodcast.com/.

Take care. Love you all!

The last of the Cephalosporins

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Tue, 07 Jun 2011 00:26:00 +0000

Antibiotics are interesting drugs. I think they are the only class of pharmaceutical agents that alternative medicine practitioners still consider beneficial. I have heard one naturopath refer to all other drugs as spawn of Satan, but I think that was a little harsh: I wouldn't exactly say "spawn." I'd say "love-child."

The reason for more alternative medicine practitioners to nod at the use of antibiotics, especially in times of disaster, is the speed by which antibiotics work when compared to natural antimicrobials. Natural medicines work much slower, taking weeks to months to accomplish what one medication will in a matter of days. Secondly, the occurrence of sexual assault, human bites, respiratory infections from dangerous soil bacteria, and some zombie bites ;-) most likely will increase during disastrous times.

As a result, sexually transmitted diseases (STDs) incidences will climb. Thus making certain antibiotics essential to have, especially those that treat Chlamydia (which can cause infertility, ectopic pregnancies, and pelvic inflammatory disease), Gonnorhea, Sypillis, Trichomonas, and any new infections that could arise in post-apocylptic situations.

In a nutshell, antibiotics are must haves. Where you get them from is your business, as long as they are from regulated pharmacies. I, personally, promote going to your preparedness-minded healthcare practitioner and explain your need for prepping with a few items, especially for travel purposes. You may get a good prophylactic prescription or two. Canada might also be a good option.

Another avenue that is popular among preppers is to acquire antibiotics from veterinary pharmacies. In fact, I have been asked a great question about animal antibiotics by a member of the American Preppers Network named Rightwing Mom. I decided to answer her here, just because it was such a good question. She asked concerning the safety and efficacy of veterinary-grade antibiotics in humans, especially fish and bird antibiotics. (Image taken from http://www.petconnection.com/blog/2008/07/09/more-veterinary-drug-alerts-from-fda/. Also, there is a lot of good information on this site as well.)

The USDA and FDA regulate the antibiotics given to food-producing animals. Thus, the antibiotics given to cattle, for instance, are more likely to be safe and effective if used in humans, as opposed to those drugs given to non-food animals such as dogs, cats, and non-poultry birds. Fish antibiotics are still ambiguous to me. Fish farms do use them, but I am not exactly sure whether these are also under the same regulatory conditions as beef. It seems that they would be, but I still remain unsure.

In order to standardize animal pharmaceutical information, the University of California-Davis, North Carolina State University, and the University of Florida run the Food Animal Residue Avoidance Databank that provides label information for all food animal drugs, especially antibiotics. For more information on veterinary uses of human-grade antibiotics in food-producing animals refer to the FARAD site at www.farad.org. (It also provides a warning news flash concerning radioactive fallout contamination of food-producing animals. I think that might be an interesting side note to look into.)

The FARAD site provides an algorithm concerning the safety of pharmaceuticals that are to be given to food-producing animals. This might be of interest to those that have thought of purchasing animal-grade antibiotics. I can not advocate this avenue, but if you do choose this route of obtaining medications, it is better that you understand all the precautions and safety issues out there.

Anyway, that being said, antibiotics are great drugs. They sometimes come at great prices, and unfortunately, they sometimes come at such high prices that your Piggybank craps its pants...because that little pig knows you're going to take a hammer to it just to get them. Third and fourth generation Cephalosporins are some of the best drugs, but they often come at a price. (Image taken from eDrugSearch.com.)

For example, one of my favorite third generation Cephalosporins, Cefixime is nearly $300 per 100 milligrams. That's the same price as two sutures during a cardiovascular surgery. Yes, two small 5-0 sutures cost a patient approximately $150 a piece, which partially explains two things: one, why cardiac surgeries are so expensive and two, why sterile sutures are hardly ever seen in preparedness kits.

Anyway, the third and fourth generation Cephalosporins are the drugs you would buy at Tiffanys or Sax Fifth Avenue. In fact, some diamonds are probably cheaper than a IV bag of the fourth generation Cephalosporin called Cefepime.

Third generation Cephalosporins cover infections caused by gram negative bacteria, such as Esherichia coli (which is responsible for the recent food poisoning outbreak in Germany), Klebsiella, Moraxella catarrhalis, Niesseria species, Pseudomonas, Enterobaceteriacae, and Proteus, etc. They also cover gram positive bugs like Staphylococcus and Streptococcus.

The fourth generation is made up of one drug in the US. Yep, Cefepime IV is all by himself, lonely and... costly. This drug covers methicillin-sensitive Staphylococcus aureus, all and I mean ALL gram negative bacteria. Cefepime may be a loner, but carries a big gun.

So let's start with the third generation drugs: They usually have a "tri", "taxi", or "tazi" in their name, with a few exceptions such as Cefdinir and Cefixime.

Ceftriaxone (Rocephin): Only administered intramuscularily or intravenously, Ceftriaxone is the drug of choice in doctor's office for one quick shot. This is a good drug for pneumonia, bronchitis, Gonorrhea, Haemophilus influenzae, Serratia, acute ear infections, septicemia, bone and joint infections, meningitis, Niesseria infections, pelvic inflammatory disease (PID), surgical prophylaxis, epididymitis, endocarditis prophylaxis, and Typhoid fever.

Adult Dosing: 1 to 2 gram IM/IV every 24 hours with a maximum of 4 grams per 24 hours.

Child Dosing: Not for neonates, especially those with hyperbillirubinemia. Children can be given 50 to 75 mg per kg body weight given once a day. The total daily dose should not exceed 2 grams.

Side Effects: Allergic reactions, watery diarrhea, and tea colored urine.

Ceftazidine (Tazicef): Also given IM/IV, Ceftazidine acts similar bacteria as Ceftriaxone, except not as much coverage.

Adult Dosing: 1 gram IM/IV every eight hours. This drug requires renal dosing adjustment to 500 mg per every 24 hours.

Child Dosing: Can be given to neonates less than 7 days old: 100 mg/kg/day divided every 12 hours. Older than 7 days old and greater than 1200 grams weight then give 150 mg/kg/day divided into eight hour doses.

Children one month to 12 years old are to be given 90 to 150 mg/kg/day divided into doses given every eight hours.

Side effects: Agranulocytosis, seizures, and C. difficile diarrhea.

Cefdinir (Omnicef): This Cephalosporin is given orally. Hallelujah! Finally, a third generation that can be eaten. Yum! It treats community-acquired pneumonia caused by H. influenzae and Strep Pneumoniae, and Moraxella catarrhalis. It also covers acute exacerbations of chronic bronchitis, sore throats, sinusitis, ear infections, and skin infections caused by staph or strep.

Adult Dosing: 125 mg to 300 mg given orally every 12 hours. For instance, the treatment dose for pneumonia is 300 mg by mouth every 12 hours for 10 days.

Child Dosing: Can be given to children older than 6 months of age. The average dose is 14 mg/kg/day given by orally divided in 12 hour increments.

Side effects: This drug can has some nasty adverse effects. For instance, it cause Steven-Johnson Syndrome, toxic epidermal necrosis, neutropenia, hemolytic anemia, aplastic anemia, serum sickness, nephrotoxicity, and hepatotoxicity.

Cefixime (Suprax): I love the name of this drug: Ce- fix-i-me S'up-ra. (Which sounds a lot like "Say fix a me up, yo."). Another good oral medication, Cefixime treats urinary tract infections, ear infections, sore throats, Gonorrhea, and bronchitis.

Adult Dosing: 400 mg by mouth once a day. For regular gonococcal infections, 400 mg once will cure it. If the condition is disseminated gonorrhea then it will take 400 mg once a day for 6 days. Children 12 years old and greater than 50 kg in weight can be given the adult dosage.

Child Dosing: Can be given in children older than 6 months of age at dosing of 8 mg/kg/day in a single dose by mouth.

Side effects: Erythema multiforme (big red spots all over your body so that your friends can nick name you spot), Steven-Johnson-Syndrome, and hemolytic anemia. Keep in mind these are rare.

Cefepime (Maxipime): Here's our fourth generation loner that lives in his basement and never comes out unless there is a great need for his superhero-big-gunness: Cefepime's mother often wonders if he will become the next Uni-bomber. Only administered by IV/IM, Cefepime is usually for complicated urinary tract infections, kidney infections, used for immunocompromised patients as infection prophylaxis, skin infections, and complicated intra-abdominal infections.

Adult Dosing: 1 gram to 2 grams by IV/IM every 8 to 12 hours.

Child Dosing: Can be given in children older than 2 months of age at doses of 50 mg/kg every 12 hours.

Side effects: Encephalopathy, leukopenia, hemorrhage, and aplastic anemia.

For all those of my regular followers that were expecting my usual absurd humor, I have to admit that I am so tired that my serious doctor mode has come out. I know, it's sad. Why did I have to be trained to be serious? But yes, it does happen. ;)

Hope you enjoyed the Cephalosporins. Next time: the Marvelous Macrolides.

TTFN.

Cephalosporins: The Next Generation

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sun, 22 May 2011 18:00:00 +0000

Cephalosporins, the next generation. That sounds like I'm starting a trailer for Star Trek. Now, all I need is some guy with a deep voice saying, "Cephalosporins will go where no one has gone before."

Man, that's creepy. Especially if you think about Captain Cephalosporin Kirk that goes after every bug princess in the galaxy. "Hey bacteria babe, how you doing?"

Contrary to popular belief, I'm not a huge Star Trek fan. If a pointy eared guy comes up to me, with a psycho split-fingered sign, saying, "Live long and prosper," I'd mace him and run screaming. Then I'd feel bad and give him the card of a plastic surgeon friend of mine. Because somebody has to do something about those ears.

Anyway, back to the message at hand: Second-generation Cephalosporins.

These are the moderators. They have no mnemonic device for their names, because their names are all over the place. As antibiotics, they have more Haemophilus influenzae coverage than their predecssors and have added coverage of anaerobes, Enterobacter species, Providencia, and Morganella. On the other hand, they have less gram positive cocci coverage. What does that mean for us? They don't cover staph and strep infections like the old timers, but they do cover more gram negative bacilli, such as Bacteriodes.

Cefuroxime: Also called Ceftin and Zinacef, Cefuroxime has more coverage of H. influenzae, Enterobacter and Proteus than Cefazolin.

Cefuroxime is administered largely via IV and has a stable shelf-life. It is approved for H. influenzae meningitis which is unresponsive to other medications. It is preferred in ampicillin-resitant strains of H. infleunzae. In addition to that it is highly active against Moraxella catarrhalis, which is a common cause of otitis media, sinusitis, cholecystitis, gonorrhea, lyme disease, tonsilitis, bronchitis, and pneumonia in patients with underlying chronic lung conditions.

Normal Adult Dosage: 500 to 750 mg by IV per every 8 hours. Treatment is usually finished up with oral dosing of 250 to 500 mg every 12 hours.

Child Dosage: It can be used in children older than 3 months. Orally 30 mg per kg per day with a maximum of 1 gram per day. IV dosing is 75 to 150 mg per kg per day with a max dose of 6 grams per day.

Cefoxitin and Cefotetan: The Cephamycin twins. These Cephalosporin twins are known for their activity against Bacteroides, E. coli, P. mirabilis, and Klebsiella. The twins are emotionally stable and take on seriously mutated beasts together.

Yet, Cefotetan lives longer than it's twin. Cefotetan has a longer half-life than Cefoxitin, making its dosing less frequent. It is also more active than Cefoxitin, because the foxy one is spending too much time at clubs.

These two drugs treat infections of the womb (amnionitis and endomyometritis), aspiration pneumonia (pneumonia caused by vomit entering the trachea), human bites (now this is a good one when the Zombies come ;) ), eye cellulitis, community-acquired pneumonia, liver abscess, pelvic inflammatory disease, and surgery prophylaxis.

Normal Adult Dosage:

Both drugs are only administered by IV or IM. 1 to 2 grams every 6 hours. If given by IM, a Cefoxitin injection is painful, but the dosing is the same as IV. Can be given up to 12 grams per day.

Child Dosage:

The twins can be given to children older than 3 months of age. 80 to 100 mg per kg per day divided into 8 doses to be given every 4 hours. Cefotetan has a maximum of 6 gram per day.

Cefaclor: Brand name Raniclor, this antibiotic is great for otitis media and pharyngitis. There isn't a lot to say about this drug. It likes to keep to itself.

Normal Adult Dosage: 250 to 500 mg by mouth per every 8 hours. If renal impairment then give 50% of the usual dosage, unless the kidney problems are severe in which case you would administer approximately 25% of the usual dose.

Child Dosage: 20 to 40 mg per kg weight of child per day divided into 3 doses, to be given every eight hours. For a maximum of 2 grams per day.

WARNING: This drug can cause a severe condition called Sick Serum Syndrome which can lead to death. Another reason why it likes to keep to itself: it's trapped in self-loathing.

Well, that's it for the second generation.

TTFN

Cephalosporins: The First Generation

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Fri, 20 May 2011 13:41:00 +0000

Cephalosporins are another group of antibiotics that have cross-allergies with Carbapenems and Penicillins. But these are my favorite group. They cover pretty much everything at a relatively low cost... kind of like thugs. You pay a small price and they'll beat up anyone you want: It's beautiful.

Cephalosporins are a great mix of guidos. Some are the brute squad that tackle the dumb masses of bugs. Others are expert snipers that pick off the hardest bacteria one by one.

So if you have a patient suffering from a mutated little nasty, you can send in Specialist Cephalosporin with his little gun and that sucker is gone in no time. It's so pretty. It brings a tear to my eye.

Basically, there are so many Cephalosporins out on the market looking for work that they formed their own class system which is grouped into generations based on age. ;)

The old timers are the first generation. They love a good bingo game and can knit a sweater like you wouldn't believe. The moderate mild mannered adults are the second generation. These guys buy minivans and live in suburbia. The third generation are the gamers, they spend their days playing video games until they reek. The fourth generation are the secret ninjas that only come out to go all Bruce Lee on some big bacteria than disappear back into the darkness of the pharmaceutical shelves.

In other words, each generation covers a different group of bacteria. For the purposes of this post, I will only discuss the first generation. In next few posts, we will discuss the other generations.

The first generation covers the gram-positive bugs such as Staph and Strep. I know what you're thinking: everything covers Staph and Strep these days. Well, that's because of two things:

One: There are more species of Staph and Strep than there are Friday the 13th movies.

Two: Staph and Strep love to mutate.

Yep, these bugs mutate more than the Teenage Mutant Ninja Turtles. More than the X-men. More than New York City sewage gators. And scarily enough, more than that glowing pizza under your kid brother's bed that he tried a dirty underwear and foot fungus experiment on.

So there you have it: that's why we have a billion antibiotics out on the market that kill Staph and Strep.

Back to the subject at hand, the first-generation Cephalosporins treat more than just Staph and Strep, they attack Escherichia coli, Proteus mirabilis, Salmonella, Shigella, and Klebsiella species as well. But they do not cover Listeria or Enterococcus.

An easy mnemonic device by which to distinguish first generation Cephalosporins is by finding an "L" in their generic name. Granted, not every first generation has an "L" in its name, there are some rule breakers such as Cephapirin and Cephradine, but the most commonly used first generations do, so it is a helpful device.

So, let's use Cephalexin as an example. Notice the characteristic "l" in the middle of the generic name. I know that the trade name also has an "l" in it, but most others don't, so we will refer the mnemonic device to the generic names.

Cephalexin: This is probably the most prescribed first generation Cephalosporin there is with the most common use for it being respiratory tract infections. These are Streptococcus pneumoniae and Streptococcus pyogenes respiratory infections.

Even though penicillin is considered the first drug of choice in treating Strep infections, there has been a lot of resistance to penicillin. Cephalexin is markedly more effective at eradicating strep found in the nose and throat.

Other indications for use include Otitis media (Strep, Staph, Haemophilus influenzae [not to be confused with the influenza virus], and Moraxella catarrhalis), skin infections, and genitourinary tract infections, including acute prostatitis (Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis)

Normal adult dosage: 250 milligrams by mouth one pill every 6 hours. Strep infections may require 500 mg every 6 hours. Bladder infections require the 500 mg every 6 hours for 14 days.

Child dosage: 25 to 50 mg per every kilogram in weight of the patient. If the child is younger than one year old then give the dose every 12 hours.

Side effects: Rash, fever, colitis, aplastic anemia, and gastritis with or without nausea.

Drug interactions: Doesn't get along well with Probenecid. I'm beginning to think that Probenicid is the problem drug since it doesn't enjoy the company of any Carbapenems, Penicillins, and Cephalosporins.

Increases the serum levels of the diabetic drug Metformin. It really likes to hang out with it, and causes decreased blood sugar levels in patients taking Metformin.

Cefazolin: Hey, what do you know, it also has the characteristic "l" in its name. This is the artist otherwise known as Ancef that is administered only by injection. I call it the prissy chick of the bunch. It needs to be diluted. It needs refrigeration. It needs you to pick out the green M&Ms out of the bowl and to bring it chocolate dipped strawberries on pink plates. Because how dare you bring it normal strawberries on white plates!

It has the same coverage as Cefalexin, but is a much more aggressive antibiotic. Hey, it's a diva. You pamper it, pay a fortune for it, and it seriously kicks tail when it does its job.

In addition to the infections that Cefalexin treats, the IV-infused Cefazolin treats gram-positive septicemia, biliary tree infections, endocarditis, epididymitis (infection of a part of the testes; men appreciate this drug), and surgical prophylaxis.

Normal adult dosage: uncomplicated conditions require 250 mg to 500 mg by IV or by intramuscular injection every 8 hours.
Severe or life-threatening conditions require 1 gram to 1.5 grams given by IV every 6 hours.

If given IM then dilute with sterile water. Inject it into the patient's butt. Yep, have them bend over. The shot is a total pain in the A.

IV for an adult can be diluted in 50 to 100 mL of any of the following: Normal Saline solution, Lactate Ringer's solution, Dextrose W, and 5% Sodium Bicarbonate. The most commonly used are D5W and Normal Saline.

Child dosage: A total of 25mg per every kg weight of child per day, to be given IV over 6 hour increments, with a dilution volume at 125 mg per mL fluid.

Side effects: Similar to Cefalexin, but needs dosing adjustments in patients with kidney failure. (Cut the dose strength by half)

Same Drug interactions as all first generation Cephalosporins.

Cefadroxil: Also called Duricef, this antibiotic has the similar coverage to Cephlexin. Cefadroxil's edge is that it is especially effective for pharyngitis or throat infections, such as Strep throat.

Skin infections and urinary tract infections are also covered by this particular Cephalosporin. And like the rest of the first generation of Cephalosporins, Cefadroxil is a pregnancy category B drug, so it is relatively safe for pregnant women to take.

Normal adult dosage: 100 mg by mouth twice a day

Child dosage: 30mg per kg weight of the child per day. This can be divided into two doses.

Other First generation Cephalosporins: Cephalothin, Cephaloridine, Cephapirin and Cephradine.

The four compadres pretty much like kicking bacteria butt as any Cephalosporin does, but these shouldn't be used in patients with severe kidney problems.

Other than that, they're great drugs. Besides, they look great in bunny ears.

Hope you enjoyed the first generation. Next time, it's the second generation, known as the moderators. ;)

TTFN

Carbapenems: Who Comes Up With These Names?

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 14 May 2011 18:09:00 +0000

There's always a scientific reason why drugs are given certain names: It's called a bored scientist with too much time on his hands is trying to win a game of Scrabble.

"Carbapenem is not a word."
"Yes, it is."
"No, it isn't. It's not even in the dictionary.""
"It's the name of a... a... um, drug that I'm creating. Yeah, that's right. It's the drug I'm working on."

Just for you, I will unravel the mystery of how names of pharmacological agents came about. The influence of the alphabet song makes its mark on the anti-platelet medication abciximab. The owners of the alphabet song are suing for copyright violations.

One scientist was up late one night watching the movie Maverick and the antiviral drug Maraviroc drug was born.

A Trekkie fan created the drug Android (an androgen receptor antagonist) after Data and his rival the Star Wars fan named the arthritis drug Anakinra after the infamous Jedi. May the force be with your anti-arthritic medication.

And if that's not fun enough, scientists get even more creative by stringing together words to form a name, just because we aren't confused enough by the goofy ones already out there.

So there are the ones named after a phrase such as bend-over-must-sting like the alkyating agent that can only be administered by shot named Bendamustine (the company even goes as far as giving it a trendy brand name of Treanda).

I'm just waiting for a scientist whom after eating a couple moldly sandwiches, gives up on a game of Scrabble to do a marathon of Lord of the Rings and youtube. Here could be the name of the newest antipsychotic medication: "Mypreciousmypreciousstarwarskidmeetswizisin."

Then there are the pharmacological agent names that are just plain cruel. These are the ones created by evil mad scientists that prefer torturing people with oxymorons.

My favorite of this category is the colonoscopy preparation called "GoLYTELY." Nothing is more of a rude awakening than this name. If it's not bad enough that you have to go in for a camera the size of Florida up your rear end, the mad scientist in his great evilness decided to psyche you out with the name "Go Lightly." Now, it's a bold-faced dirty lie; there is no "lightly" about about it. In fact, historians believe that Go LYTELY used to be an explosive device created by secret agents to turn vegetarians into salad shooters.

But at any rate, some socially-poor-but-economically-rich schmuck coined the term Carbapenems from the phrase "carve a pretty penny out of them" and we have a really cool class of antibiotic drugs; some of which are quite expensive.

Like, I mentioned in the last post: Carbapenems have cross-allergies with penicillins. So if a penicillin puts a rash spawned by Hitler on your butt then carbapenems try to match it with a rosy rash of their own.

The Carbapenems are a class of antibiotics that attack the cell wall of susceptible bacteria.

They cover a wide spectrum of bacteria. Carbapenems are kind of like Scarface with his big-A machine gun, shooting up everything. "Say Hello to my little Carbapenem!"

Seriously, Carbapenems are the big guns, saved for the life-threatening cases. And following the grand tradition of all hard hitters, they are administered IV. So, you have to get your butt shot before you feel their effects.

Carbapenems handle meningitis (Meropenem), sepsis, endocarditis, ventilator-associated pneumonia, urinary tract infections, bone infections, and complicated intra-abdominal and pelvic infections.

In a few words, they cover the gram-positives like Strep and Staph, similar to the penicillin group, but in addition to that, they also cover some seriously nasty gram-negatives and a few strains of Pseudomonas. But they don't kill Legionella or MRSA. Too bad. Oh darn, the elderly are going to have to avoid sitting near old air conditioners and MRSA sufferers are going to have to find some other drug. Yet they kill anaerobes! So, they are good for bullet wounds and some scary stuff that that incubates in the gut. Woohoo!

The one major flaw with the Carbapenem class is that they can cause dangerous seizures in patients with kidney problems. Have bad kidneys? No Carbapenems for you!

Ertapenem: Does not cover Pseudomonas. It's the only Pseudomonas-lazy Carbapenem out there. It's so lazy that it doesn't even have the gram-positive bug coverage that the other drugs in this class have. So if you're a burn patient with Pseudomonas or have a serious gram-positive bacterial infection, then don't bother with this drug. It will just disappoint you. You'll end up hating each other and heaven knows if it will try to sue for your house. But it is a pretty cheap date, if you're not into spending a lot of money and don't care about Pseudomonas.

And you might as well know that cheap dates like Ertapenem are often antisocial losers: it hates to work with the bipolar medication valproic acid (Depkote) and the drug Probenicid. They fight a lot.

Ertapenem does have its good points: it is a category B drug and is relatively safe to take during pregnancy and while breast feeding. Also, it loves kids older than 3 months old. So it's kid friendly.

Trade name Invanz, Ertapenem is only administered by injection. And just like a cheap Coyote-Ugly needs a shot of Vodka, Ertapenem needs a shot of lidocaine prior to administration just so you can handle dealing with it.

Not at all good for meningitis, but is awwwwwesome for intra-abdominal infections, urinary tract infections (use as last resort), community-acquired pneumonia (if Azithromycin doesn't work), and wound infections.

Normal Adult dose: 1 gram of Ertapenem by IV once a day over a course of 5 to 14 days depending on the severity of the condition.

Side effects include increased platelet count, vaginitis, altered mental status, chest pain, and liver enzyme elevations.

Imipenem: Trade name Primaxin, this Carbapenem includes Cilastatin. Not to be used with antivirals or cyclosporine. Also, not good for our pregnant friends, but loves children. Takes walks on beaches in the moonlight and is not so antisocial as its cheap-A brother.

Imipenem is used for endocarditis. Okay before I continue I have to state some of the ground rules of catching endocarditis. If you are a needle-drug user, you will get endocarditis. Generally this kind of endocarditis is caused by Staphyloccocus. No ifs-ands-or-buts, IV drug users will get endocarditis at some in their drug-using career. Night sweats, chills, unexplained sickness that lasts for weeks with a racing heart rate sometime after heroine injection equals bad case of endocarditis.

People that have heart valve problems may get Streptococcus mutans/viridans endocarditis from visiting the dentist. So dentists generally give prophylactic antibiotics to prevent it. Imipenem is used to cover these difficult cases of endocarditis and it is administered intravenously.

Other conditions that it covers include serious gynecological infections, intra-abdominal infections, sepsis, lung infections, bone/joint infections, Pseudomonas, and multi-bacterial infections.

Normal adult dose: 500 milligrams by IV given every 6 hours over the course of 10 days.

Side effects include confusion, drug fever, psychic disturbances, and in patients with kidney failure, seizures. So don't give it to Psychics with renal failure that want to drive buses.

Meropenem: Also called Merrem IV because it is given only by IV, this Carbapenem has some serious side effects like Stevens-Johnson Syndrome and Angioedema. Yeah, I hit you up front with those. I didn't wait to get you all excited about this drug, make you fall in love with it, and then smack you down with the "this drug can kill you if not used properly" statement. See, I care about your feelings.

One phrase for this drug: Kicks the crap out of meningitis. Yep, this one takes the Louisville Slugger and beats the holy snot out of any gram-positive bug that even dares to venture into your meninges. This is the drug that you would want to marry if you suddenly get "the headache that kills" and trust me, it won't disappoint you. It also can be used for complicated pelvic/abdominal infections such as appendicitis and peritonitis as well as serious skin infections.

Normal adult dose: 1 gram by IV per every 8 hours over a 10 day course.

But as you know, with any classy date, there comes a hefty price tag. This is one expensive drug. Sell your car and your house... and maybe a few of your children and you can pay for this Carbapenem, because it will "carve a pretty penny out" of you.

So that ends my discussion of Carbapenems. There are no more in the class. I think Ertapenem's antisocial behavior has ruined the chances of any other antibiotics joining them. Well, technically there is Dorkipenem (Doripenem) but he's the really really really expensive brother.

The following is a good site concerning wound infections, bacteria, viruses, etc. that is totally worth reviewing:

World Wide Wounds

TTFN.

For all those Star Wars Scientist fans out there when Scrabble isn't good enough:

Bugs and Penicillin Drugs

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Mon, 09 May 2011 01:15:00 +0000

Before you go to the black market to buy antibiotics and a kidney for Uncle Earl, there are somethings that you should know.

One: Kidneys are hard to get past the TWA. They like to collect them. It's a hobby.

Two: Not all antibiotics are created equal. Even the Founding Fathers, Martin Luther King, and Bugs Bunny would agree.

Some antibiotics cover bacteria that cause upper respiratory infections, while others treat bladder infections and entercolitis. Some treat sore throats and some treat STDs. But none of them treat viruses. You see there is some old school thought that antibiotics are superheroes that fight crime, leap tall buildings in a single bound, and cure the common cold. Not going to happen. Penicillin won't stop H1N1. The Z-pack won't stop a bullet. And Ciprofloxacin won't bring your ex back. Not going to happen.

Antibiotics have their limitations. So for the next few posts, I'm going to talk in depth about the different classes of antibiotics and what they are best used for.

The first class of drugs are called the penicillin family. Penicillin was discovered when a scientist left his moldy sandwich close to a petri dish filled with nasty bacteria. Seriously, who does that? Who leaves their sandwich next to a growing pile of killer bacteria? What was he trying to do? Save it for later? Yum.

Anyway, the mold on the sandwich annihilated the bad bacteria because it was the freakishly powerful penicillin. Bwahahaha!

Thereafter, penicillins have saved millions of lives over the years, especially during the World Wars. So kudos to that perky mold sandwich, it saved the day.

Personally, I have a love-hate relationship with these antibiotics. Penicillins love to give me a rash the size of Kansas. And I hate the swollen tongue and gasping for breath that comes afterwards.

Every class of antibiotics has a chance of causing an allergic reaction: we can't necessarily play favorities. But I do want to mention here the cross-reactions between penicillin allergies and those to certain other classes of antibiotics.

As much fun as it is to watch a patient balloon up after administering a drug, we doctors don't like doing it. So we try to avoid giving penicillins to people whom have already demonstrated allergic reactions to cephalosporins and carbapenems. And vice versa due to cross-reactivity between these classes. Cephalosporins and carbapenems will be discussed in later posts.

Penicillins are beta-lactams. What does that mean for us? Diddly squat. That's a scientific term that I would rather put a red-hot poker through my eye than explain. But what we can take away from this is that the penicillin class of beta-lactams has some serious weaknesses.

Let's put it this way. Bugs are smart. The mutated little beastards have figured out a way to kick the living snot out of penicillin beta-lactams, rendering them less effective against certain super chains of bugs. Freakish beastards.

So what are penicillins good for? That's a good question. They treat infections caused by gram positive bacteria, such as Streptococcus and Staphylococcus... and okay, anthrax as well (yes, anthrax. Penicillin can kick anthrax butt). Some listeria coverage and there is also syphillis and gonorrhea coverage. See STDs had to sneak in there somewhere. (Image taken from http://www.newworldencyclopedia.org/entry/Penicillin)

And you're thinking, darn I left my microscope in my other camping jacket... so can you just tell me what conditions I can use the blasted drugs for.

Oh, sure. Why not? It's not like I have a 7:00 am surgical case that I have to get to tomorrow morning. ;-)

(Before I continue, I must again stress that penicillins are only to be used in patients that do not have penicillin, cephalosporin, or carbapenum allergies.)

Here are a few examples of what antibiotics in this class are used for:

Amoxicillin is the pediatrician's favorite drug for otitis media or ear infections. It is also the first line choice for Strep throat and prevention of bacterial endocarditis in patients with heart valves undergoing dental work. It can be used in anthrax treatment and prophylaxis. This drug has all but replaced penicillin in a lot of conditions.

Ampicillin: I love this drug. It's the only penicillin that won't kill me. I appreciate that. Technically, this drug belongs to a subclass of penicillins called the aminopenicillins, which were created to handle more resistant strains of bacteria. Others within this class are Augmentin (Amoxillin + clavulanate, which has more gram negative bacterial coverage than other penicillins), Unasyn (Ampicillin + sulbactam)

This drug has beautiful gram positive coverage and some gram negative coverage. This is your urinary tract infection drug, because it goes all WWF smackdown on Escheria coli. It also is the drug of choice for listeria meningitis. Ampicillin is one of the few penicillins that can cross the blood brain barrier. If you have a resistant case of meningitis in an immunocompromised patient, especially if he/she is an infant less than one month of age, give them ampicillin.

Unasyn is a more aggressive form of Ampicillin with more coverage of bugs such as Serratia, Enterobacter, Pseudomonas (swimmers ear and wound infections in burn victims), and Legionella (air conditioner related pneumonia in elderly). It's general indications are for gynecological, intestinal, and skin infections.

Oxacillin: This one's fun, because it's named after a bull and can seriously kick bacteria bum. Oxacillin treats recurrent Group B Strep (GBS) infections and is great for pregnant women when ampicillin doesn't work and for neonates suffering from GBS infections. GBS is transmitted through the vaginal canal during delivery to the infant. If there is a vaginal delivery at home, the chances are that the baby is going to acquire a GBS infection and could die. GBS infection signs of fever, lethargy, grunting, nasal flaring, pale or blue appearance, and difficulty feeding occur mostly within the first 24 hours but can occur up to 6 days of life.

Note: Oxacillin can only be administered via intramuscular injection or intravenously. Neonate doses are approximately 50mg/kg/day every 12 hours.

Timentin: A combination drug (Ticarcillin + clavulanate), Timentin is similar to Augmentin but doesn't cover Legionella. Yet, it covers Clostridium difficile, which is the most foul-smelling diarrhea you will ever smell. It makes Giardiasis smell like roses. Consider it a kind of Post-traumatic Stress Disorder for your nose, because if you smell C. diff once, then you will never mistake it again.

C. diff is the diarrhea most common in hospitalized patients which are already on enough antibiotics to kill an elephant. The most common antibiotic associated with acquiring C. diff is Clindamycin. So if you have a patient that was given Clindamycin and afterwards, suddenly gets the Great Stink of all diarrhea then you pretty much can guess it is C. diff. Treat them with Timentin or oral vancomycin and be done with the juicy squirts.

Zosyn: The brand name for piperacillin + tazobactam, Zosyn has the same coverage of the aforementioned penicillins, but with increased ability against Pseudomonas. This drug should be used in conjunction with an aminoglycoside to cover severe pseudomonas infections in burn victims. You can tell a pseudomonas infection by its characteristic blue-green color it causes in wound tissue and the sweet grape-like scent.

Okay, who was the guy that said, "Mmm! I so want to sniff that wound. I bet it smells like grapes."

Well, I hope you enjoyed my ode to penicillins.

TTFN

Code Brown

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 07 May 2011 22:51:00 +0000

Do you ever wonder what would cause doctors to run screaming in terror? The answer is a Code Brown. (Image taken from maxupdates.tv.com)

In the hospital setting lots of codes are used to notify personnel of important and dangerous events. For instance, Code Blue means cardiac arrest. Code White generally means stroke. Code Pink means an infant has been kidnapped. Code Black can mean act of terrorism or bomb is on the premises depending on the hospital. Code Red or Orange generally means fire. Code Brown is much much more dangerous... it's patient diarrhea.

I was rounding with the usual herd of doctors and medical students, when we came into the room of an inebriated patient. He was a frequent-flyer for his alcohol and was on a withdrawl protocol which included him wearing nothing but a hospital gown. When asked who he was he stood up proud and tall and said, "Abraham Lincoln."

Just then a tsunami of liquid brown Montezuma's revenge shot out of him all over the floor and on the shoes of a couple residents. After a few girly screams from the men, someone shouted, "Code Brown!"

You should have seen the stampede of doctors rush out the room. I think my attending physician knocked over a couple nurses and a beefy orderly to get out. People were flying. Doctors were gagging. One managed a "Diaper change stat!" between his dry heaving.

Only the third year medical student remained in the room like a deer caught in headlights. The poor guy froze in terror as the Great Stink filled the air around him in tufts of gas that smelt worse than-a-skunk-taking-a-bath-in-a-garbage-can-after-eaten-a-rotten-corpse. Fortunately, the nurses rushed in to save the day. Nurses are heroes.

In the wilderness and disaster setting, diarrhea is not so comical. It actually can be life-threatening. Cholera-- which is a glorified name for explosive watery diarrhea-- killed thousands in the past and still kills many in developing countries today.

The mechanism by which diarrhea becomes dangerous is through the profuse excretion of vital electrolytes in the constant bowel movements. It is through an osmotic effect in your bowel. Yep, that's definitely what you want to read about. You've set down with a big beefy burger about to take a bite and I'm talking to you about explosive bowel movements. Yummy.

Anyway, back to what I was saying before: this massive electrolyte loss results in heart arrhythmias which develop into heart attacks. So the Centers for Disease Control and the World Health Organization have developed inexpensive means to counterbalance this.

Now just so we are on the same page: I'm only talking about diarrhea here and am not including dysentery (bloody diarrhea), pandemic flu (unless it is a strictly diarrheal flu), and zombie attacks (which cause you to crap your pants).

The first part of the treatment: Measure the diarrhea/liquid lost from the body and give the patient the exact same amount in clean or sterile fluids.

As for replenishing electrolytes, I've gathered together some options that you can do at home or in the wilderness:

First option: Mix one Liter of clean (sterilized, boiled, or filtered ) water with Two Tablespoons sugar and one-half tablespoon of salt. Mmm yummy.

Second option: Pedialyte, Infalyte or equivalent medical electrolyte drink. Moderately expensive.

Third option: 1/2 strength Gatorade. I like this one personally. Gatorade is always on sale. And the mixture is one part water and one part Gatorade. Simple. Quick and it replenishes fluids and electrolytes at the same time.

Fourth option: Hikers electrolyte packs. One pack per liter of water.

Fifth option: I call this the kid friendly option is fruit pops, popsicles, or Jello. Man, I love Jello's versatile nature.

Naturally Disastrous Diarrhea:

In disaster settings, profound cases of diarrhea appear when sanitation gets ignored in the face of calamity. I know. I know. The last thing on your mind when an earthquake or tsunami hits your house is "darn, now where am I going to go the bathroom?"

As you all know, contamination of drinking water is imminent. Diarrheal cases increase, some of which can be infections similar to those found in developing countries, such as typhoid, E.Coli strains, Clostridium difficile and cholera. The key to managing these conditions is lots of clean water and electrolytes as mentioned above.

Most common overall regardless of disaster or not, viral gastroenteritis or the "stomach bug" is a watery diarrhea with aches, cold symptoms, chills, and nausea and vomiting. These are also treated with rehydration and electrolytes but are not nearly as severe as the above mentioned conditions.

I do want to mention one more form of diarrhea, which technically classifies as a dysentery condition, but in light of the earthquake, tsunami, and nuclear power plant disaster in Japan, this condition is worth mentioning.

Radiation enteritis is an inflammatory condition characterized by bleeding and painful straining during bowel movements. The diarrhea results from malabsorption due to inflammation of the mucosal lining of the intestines. This condition can persist for 2 to 3 months even after treatment, which is surgery. Yet, avoiding dairy and fats can help alleviate symptoms and promote nutrient absorption. Also, this is the one condition which I will suggest taking loperamide to prevent diarrhea.

Wild Bowels in the Wilderness:

The diarrheal infections in the wilderness setting are much more manageable than those found post-disaster. Giardiasis and Staph aureus are the most common types found in backpackers. In fact, giardiasis is so common that it is called backpacker's diarrhea.

Staph aureus diarrhea is the Mario Andretti of diarrheas. It acts up fast, it moves fast, and it goes away fast (unless you are immunocompromised). Staph diarrhea usually occurs from improper washing of camping dishes in non-sterilized water. Within 4 hours after ingestion, a profuse watery diarrhea and stomach cramping begin. Doesn't generally require treatment due to the fact that it lasts up to 24 hours in non-immunocompromised people.

As for Giardiasis, it's as slow as your grandpa Harold. It takes anywhere from 1 to 2 weeks after exposure for symptoms to start. So if you go camping, don't hold any board meetings or go to classy place 1 to 2 weeks afterwards. Trust me, it won't be pretty.

Giardia comes from drinking river or lake water in mountainous regions.

Symptoms include putrid smelling flatus (sorry bean burritos didn't do it to you), egg-smelling halitosis, watery diarrhea or greasy stools, abrupt onset of abdominal cramps, fever, bloating, nausea and vomiting. These symptoms are cyclic and occur over months with short periods of relief then the cycle begins again. Giardiasis can last for years if not treated. The first line treatment is metronidazole (Flagyl). (See http://www.drugs.com/metronidazole.html for more information on Flagyl.)

I hope you enjoyed this explosively squishy post.

TTFN.

Lobsters are Hemostatic Agents Too, Part II

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sun, 17 Apr 2011 15:22:00 +0000

Okay, so there are no lobsters in this post. I know, I know: it's sad. I'm crying inside too. So for all those missing lobster references, I have decided to include this adorable picture. Who couldn't love that little lobster's face?

When I edited my last post, I half-wondered how many people went searching on the net for homemade chitosan recipes. "Mmmm tastes like lobster." Again, I must stress to the adventurous teenagers out there: Chitosan is not to be covered in butter and eaten, even if it is made from lobster exoskeletons.

Anyway, onto the next group of hemostatic agents.

Thrombin

Topical thrombin products like Evithrom, Recothrom, and Thrombin-JMI are considered part of the biologic hemostatic agents group. Naturally derived from an enzyme involved in hemostasis, thrombin products promote the body to form clots.

Sixty years ago in some dark castle without cable TV, some mad scientist got bored, thought "hmmm, I wonder what would happen if I churn blood like butter" and now we have thrombin. "It's alive! It's alive!"

Seriously, thrombin was isolated from clotted blood products sixty years ago and now we have a perfectly bio-identical hemostatic agent. Happy day.

Thrombin products come in several different types based on the type of plasma it was made from. Cow plasma products such as Thrombin-JMI (King Pharmaceuticals). These products can produce severe histamine reactions and increased antibodies in hemodialysis patients. So the side effects in some individuals have been dangerous increases in coagulation like pulmonary embolisms and on the opposite spectrum, severe decrease in clotting leading to hemorrhage and death.

Not a good choice to use as a hemostatic agent unless you want to create an even bigger mess. "Darn! The cow killed another one." (Image from http://skirmisher.org/weird-shit/cow-chucks-grass-prefers-live-chicken-dinners-as-next-best-thing-to-kfc/)

Companies such as Evithrom, Omrix, and Johnson & Johnson developed human plasma derived thrombin, which has less side effects.

Recombinant human thrombin products like Recothrom (ZymoGenetics Inc.) were also created by companies to reduce the amount of side effects that occurred with thrombin administration.

Cyanocrylates

Dermabond: Need I say more. It's a beautiful product that is commonly known about. People love it, because its the superglue of suturing products.

The cyanoacrylate family of agents are liquid monomers that reapidly react with water to form glue-like polymers. Dermabond and other cyanoacrylates are great for replacing sutures. These are more a class of wound closure products than hemostatic agents, but they deserve some attention. Otherwise they will feel left out and develop psychological issues... and have to see counselors spending hours talking about how we didn't give them attention and so that's why they have to go steal stuff from dollar stores. So, let's talk about cyanocrylates.

They were invented in 1942. A lot of the most amazing medical devices, surgeries, and triage advancements were developed in World War II. The worst war in the world's history produced some of the very best medical inventions of the 20th century. Then in Vietnam, another tragedy of humans killing humans, medicine again benefited from the heroic deeds of military medicine.

Dermabond and its constituents (octyl-2-cyanoacrylate, butyl-2-cyanoacrylate) have the advantages of rapid application, faster tissue repair time, and less need for suture follow up. They also act like waterproof barriers. (The following image shows a shoulder wound sealed with dermabond instead of sutures. Image taken from http://www.orthosupersite.com/view.aspx?rid=25358)

Dermabond and superglue originally evolved from the same product back in the 1940s and so have very similar capabilities. I have talked about superglue as a wound sealant in a past post.

Superglue can be a good disaster medicine tool. It is around the house, easy to come by, and has many of the same properties as dermabond, but with some major flaws: Superglue cannot and should not be used in deep and/or jagged-edged wounds. It also is acidc in nature and produces a chemical burn to tissue it touches. Lastly, it bonds to skin extremely well and a naive person can get glued to their patients... which works well for those loving couples that never want to be separated. But as for the rest of us who want to move on in our lives, superglue should be used with caution. Also, for the love of all that is medical: please don't use superglue (or dermabond) in armpits and buttcheeks. Not a pretty picture.

Dermabond, on the other hand, was chemically created to have a less acidic nature than its commercial cousin, but it does have its own cons. Just like superglue, it is not a good agent for wounds with jagged edges. Also, dermabond can easily breakdown in the presence of antibiotic ointments or petroleum jellies. (A good rule of thumb is to avoid scrubbing the wound or applying anything to it for 7 days after dermabond use.)

Cyanoacrylates are largely used for stopping bleeding in small wounds as a waterproof barrier, which makes them great in wilderness and disaster settings where rain and flooding can be more prevalent. As for their fastness, full binding strength is achieved in less than 2.5 minutes.

Glutaraldehyde Cross-Link Albumin Agents:

Okay, glutaraldehyde cross-link albumin agents is a mouthful to say. So let's just call them Glutes, because everyone can handle Glutes a lot better.

Glute products, like Bioglue, are most commonly used in cardiovascular surgeries, especially those involving aortic dissections and valve replacements. These are produced from companies like CryoLife and created in 1999. They come in cartridges and yes are shot into the wound. Before a bunch of crazy teenagers gets excited about shooting stuff into people's wounds, Bioglue products act more like cheese-wiz then staple guns.

Guess what. These producats are also made from cows. So the next time you're eating that steak, just think, that T-bone could have been a hemostatic agent. Mmmm Mmm good!

The cons with these products are that they may have mutagenic effects. So forget about the vat of toxic waste or the radioactive spider, you can be a superhero from messing with your Glutes. These are another product that shouldn't be applied near nerves and may also cause allergic reactions.

Morals of today's post: Cows can kill. Superglue is your friend or it can glue you to your friend. Don't stick glue in armpits or on butt cheeks. And handle your Glutes with caution.

Well, that's enough medical talk for today. TTFN.

Lobsters are Hemostatic Agents Too, Part I

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Tue, 22 Mar 2011 16:51:00 +0000

You know there is something to be said about the ingenuity of our current hemostatic agents. I mean seriously, who would've ever looked at a lobster and thought, "Hmmm, I bet that's going to make a great hemostatic agent.

Well, some smart and now rich beastard did, and as a result we have Chitosan, one of the most common hemostatic agents on the market. (Chitosan is derived from chitin found in the exoskeletans of crustaceans.)

Another brilliant hemostatic agent made from something you wouldn't expect is Arista, which is a polymer made from potato starch. (Image taken from http://www.flickr.com/photos/beckendorf/ )

So we have hemostatic agents from sea cockroaches and Idaho spuds. In addition to those, there are less commonly known but just as ingenious hemostatic agents that deserve attention. The following is a starter list of the various products out on the market.

Gelatin Foams:
There is always room for jello.

Normally, I like to promote gelatin powder, which is a nonsterile, but effective hemostatic agent. Why? Because it has a few added benefits:

First benefit: You will not get hauled to the nuthouse for using powdered gelatin as a clotting agent. "I swear she said a lobster would stop the bleeding!" equals time in a loonybin.

Second benefit: It is a fast clotting agent that is very easy to buy. Seriously, you don't have to drive down to Mexico and beat off drug cartels to get it.

But for the purposes of this post, I am going to talk about the more surgical grade gelatin foams. Who doesn't love a good foam? Gelatin foams began to be used in 1945 and were manufactured from the gelatin found in animal hides. These gelatins were whipped and baked until the formed a sponge foam.

They come as a powder which you mix with a sterile saline solution (preferably) or sterile water to form a paste.

These products include: Gelfilm, Gelfoam, and Surgifoam. Gelatin foams create a type of matrix that instantly clots a wound site. These are used mainly for small blood vessel bleeds, bone bleeds, and venous seeping.

The benefits are that they are absorbed by the body within 4-6 weeks, have a neutral pH, and are nonantigenic or don't cause antibody reactions.

These can be used with oxidized cellulose wrapping. (This is shown in the Springer image to the left)

There are some cautions with these products. Gelatin foams swell. So, they should not be used in closed spaces within the body, especially near nerves.

Truthfully, you shouldn't be sticking anything, even your hands, in people's bodies to begin with if you are not a trained physician. This goes double for procedures in wilderness and disaster environments. So keep your hands out of other people's orifices. Leave that for us doctors: We get selfish over those things. "My prostate exam. Mine. Mine. Mine."

There are particular surgical techniques that we use gelatin foams for which include penetrating traumas where organs are pierced through. We use an oxidized tubular plug filled with gelatin foam, which is held intact by titanium clips or sutures, and insert it into the hole. I'd tell you more but the rest is a trade secret. ;)

[Note: Trade secret is another term for "I'm not telling just to prevent a bunch of doped teenagers from trying it with their grandma's green jello and a straw."] (Image taken from http://simplyrecipes.com/recipes/grandmas_pineapple_cucumber_lime_jello_salad/)

One of the companies that manufactures gelatin foam products is the Pharmacia and Upjohn Company, which is a subsidiary of Pfizer.

I still prefer gelatin powder, because it's around the house. In fact, I have used a mixture of gelatin powder, a few drops of sterile water, and some topical antibiotic on a baby's hemorrhaging wound and it worked effectively within seconds.

For more information on Gelfoam.

Oxidized Cellulose:

These products are called Surgicel Nu-Knit and Surgicel Fibrillar. Developed in 1942 from decomposing wood pulp to regenerate cellolose fibers, oxidized cellulose conforms more rapidly to its surrounding environment than any other hemostatic agent. (Image provided by the medical kit company Baycan http://www.baycanmedikal.com/eng/index.php?option=com_content&view=article&id=14)

Oxidized cellulose creates a clotting matrix that has a consistency similar to cotton. With its low pH, oxidized cellulose has a great antibacterial effect. It doesn't stick to surgical instruments or gloves and it typically dissolves in the body in 2 to 6 weeks.

Do not moisten before use, because it has a greater hemostatic capability when it is dry.

Cautions: It may cause inflammation of the surrounding tissue, so don't use it anywhere near nerves. And for the love of all that good and holy, don't use it on hemorrhoids; it's not a pretty picture.

It is manufactured by Ethicon, Johnson & Johnson.

Bone wax:
Historically, bone wax used to be a mixture of salicylic acid (made from the inner layer of white willow bark), almond oil, and beeswax. (Image taken from Cardinal Health showing their product Sharpoint Bone Wax http://www.cardinal.com/us/en/distributedproducts/ASP/901.asp?cat=surgerycenter)

Currently, surgeons use a nonabsorbable mixture of paraffin, isopropyl palmitate, a wax-softening agent, and beeswax. They apply is to the cut edges of bone to stop bone marrow bleeds. It blocks the bleeding channels in bone marrow, and is easy to handle. You seriously just wipe the stuff on the bone edge like a jelly puddy, but after you are through clotting the wound remove as much of it as possible to prevent bone granulomas from forming (only in 2% of cases).

I have seen bone wax used to stop bleeds from the cut edges of the sternum during cardiothoracic surgeries.

Companies like Johnson & Johnson and Ethicon Inc. market and sell bone wax to hospitals.

Ostene:
This is a pluronic copolymer blend that is a biocompatible alternative to bone wax. They look and feel the same. The use is similar to bone wax.

The only difference is that ostene is water soluble and bone wax isn't.

This is marketed by Ceremed Inc. in California.

Microfibrillar Collagens:

You know when a group of hemostatic agents have enough different names to put a CIA agent to shame, they are seriously cheap to create. Some of the products within this group include Helistat, Helitene, Ultrawrap, Avitene Ultrawrap, Instat, Avitene, EndoAvitene, Avitene Flour, and Avitene Ultrafoam. (Image is of Avitene Flour taken from Bristal Healthcare which is a distributor of these products http://www.bristalhealthcare.com/avitene_63.html)

These products are made from cows. No. Rubbing a cow on your wound doesn't work either.

These products come in various forms: sponges (Aviten Ultrawrap, Aviten Ultrawrap, Helistat), pads (Instat), fluffy white powders (Instat powder, Helitene, and Avitene Flour), and nonwoven compressed sheets (EndoAvitene, Avitene).

Microfibrillar collagens (MFC) work by increasing the surface area for platelets to react upon. Platelets are blood cell fragments that are involved in clotting. Hemostatsis occurs within 2 to 5 minutes. It doesn't swell and is absorbed within 8 weeks.

Because MFCs work through platelet clotting, these are not effective in patients who have thrombocytopenias. On the other hand, it works exceptionally well in patients with normal platelets even under massive amounts of heparin.

Other facts: MFC is most successful in treating a large oozing bleed. It sticks to gloves, so it should be applied with DRY surgical instruments. Also, remove excess MFC from the wound site because it binds to nerves and dermatome surfaces causing pain and numbness.

Companies that manufacture these products include: Davol (Avitene Flour, Avitene, EndoAvitene, Aviten Ultrawrap and Ultrafoam), Integra Inc. (Helitene and Helistat), and Ethicon Inc. (Instat).

Morals of the story: Keep all hemostatic agents away from nerves. Keep your hands out of bloody holes. And don't use expanding hemostatic agents on your hemorrhoids.

Have a nice day!

This is Christine your friendly neighborhood medical blogger signing off. TTFN!

Truthfully Turmeric

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 19 Mar 2011 02:08:00 +0000

Before I begin with the wonderful and talented Mr. Turmeric, I do have to explain why I have been absent for the last year.

I know. I know. It seems like forever. And I still owe your for all the search parties you sent out looking for me. And for calling all those cops to see if my body was found dead in a hospital somewhere from the stress of medical school and board exams.

But I have an excuse for my hacker's tan and alien-abductee-style disappearance: I was preparing for my residency. Hey. Don't blame me: the application process is evil spawned by satan. So evil and twisted that scientists have been studying its affects on the minds of future doctors for years. It is up there with the Spanish Inquisition and forcing people to watch Barney. Scientists have linked it to eye twitching, nail biting, empty bank accounts, and butt-kissing-chapped lips.

The process involves some seriously complicated steps, involving ticking off environmentalists and being filled up by every airport security official for 10,000 miles.

Step one: Fill out enough paperwork to kill six rainforests and the cherry trees in your backyard. This is done to get you to learn how to brag about yourself.... Some scientists believe that this is the basis for the Doctor's God-complex.

Step two: Pay enough money to make Donald Trump smile. This step ensures that proper handling of your paperwork is made.... Well, proper as in... ahem... series of online disasters resulting in deep and mystical wonderments as to why any of the application materials were on paper to begin with. Note: The majority of applications are done online. You just tricked into doing secondary applications for some of the residency programs that believe in further torture.

Step three: Get fat on airplane peanuts and get enough action from TSA patdowns to last ten marriages. I swear a few of them buy me dinner afterwards.

Step four: Go through interview interrogations that would make the CIA proud.

Step five: Live the life of an insomniac worrying over whether or not you'll get into a residency program.

Step six: Find out that you matched to a program. Spend the next few days twitter-pated that God blessed you with the perfect residency program that will turn you into the kind of doctor that you have been hoping to become.

Step seven: Suddenly realize that you're going to be medically responsible for saving lives.

Step eight: You're still stuck on step seven. The shock is just too much. ;)

Now, that's why I have been busy. :D

The Talented Mr. Turmeric

Related to ginger and galangal, turmeric is a spice ground from the dried rhizome of a yellow flowering perennial plant found in India known as the Curcuma longa or Curcuma domestica.

Turmeric is used as a major ingredient in curry and has been proven to have strong antiinflammatory properties. In Europe, turmeric has been used to provide relief for stomach ailments, gallbladder conditions, rheumatoid arthritis, and as a potential adjuvant immunosuppressant.

The active ingredients in turmeric are volatile oils called curcuminoids, the most widely studied of which is curcumin. It has been shown to have antiviral, antineoplastic and antioxidant properties.

But the property that I want to talk about here is its pain killing ability. Yep, your curry cuts pain by being a Cox-2 inhibitor. A study in the Journal of Natural Remedies showed that a dose of 100mg of turmeric had significant analgesic properties.

Mix 1 tsp of turmeric with 1 tsp of neem and 2 tsp of ginger with water to make a paste. Spread the paste on the affected area and then wrap with a bandage. Drink 100mg/kg of turmeric with 1 cup of warm milk before bedtime.

Seriously?! You seriously have to eat that much turmeric? Well, yeah, if you went to Walmart and bought that $0.50 cent turmeric. Now, don't give me that it was on sale. I buy my shoes on sale, but I don't use them treat someone. Okay, well, I use them to treat me. :D But retail therapy is an entirely different story.

Turmeric needs to be purchased in pharmaceutical grade quality curcumin or perhaps storing the actual plant in your basement along with a stock pile of lidocaine would be good too. Either way, turmeric is a good analgesic in times when lidocaine is unavailable.

Edit: The above paragraph compares turmeric with lidocaine. Unfortunately, that is like comparing apples to oranges. Or it is like comparing lidocaine to ibuprofen.

Yet, I had asked one of my attending physicians what could be used instead of lidocaine as a wound analgesic, and he did say turmeric paste. Turmeric acts more like ibuprofen than lidocaine... so therefore I admit my error.

I also want to include a link with more information on the wonders of turmeric:

http://www.umm.edu/altmed/articles/turmeric-000277.htm

Hormones: the Bane of Woman's Existence

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Mon, 02 Aug 2010 19:42:00 +0000

If hormones aren't the curse of women, I don't know what is.

It's not like our lives are hard enough with high heels, anorexic super models, childbearing, but we also have to get a high does of hot flashes, bloating, cramps, and PMS.

I blame it all on Eve. She just had to listen to that nasty snake and eat that forbidden apple... Fine! Well at least, she got a good taste of fruit. But what about the rest of us? Yeah, we get night sweats and problems sleeping and mood swings, all for nothing! I feel gypped. (Image taken from http://christophermattix.wordpress.com/category/food-for-thought/page/3/)

But I do have to hand it to God for providing women with means of coping: chocolate, ice cream, support groups, sappy romance flicks, and those video games where a woman character can beat up men.

Yep, for some reason taking female hormone issues out on men has a gratifying sense to it. For instance: Where do you think the idea that men should take out the garbage came from? Come on don't give me that look. You know it as well as I do. Think about it: Who else would come up the idea that men should cart stinky crap outside into the heat?

Anyway, let's talk about Progesterone. I know, men complain about estrogen all the time. Yeah, well women complain about testosterone. But no one should complain about progesterone; it's the feel good hormone. It's the one that we should all come to love and enjoy. It's the hormone that helps women get some sleep, avoid hot flashes, have better memories, and just plain feel peaceful. Well, that is when it is in balance.

Okay, if you are a man reading this: No, I don't suggest that you run out and buy your woman progesterone to keep her from getting mood swings. Just stick to the chocolate. It's safer and more romantic.

You return with a paper bag of progesterone instead of a box of chocolate, and taking out the garbage will be the least of your worries. [Note: some women, like me, are allergic to chocolate and would prefer the progesterone.]

What's the big deal about Progesterone?

Progesterone is a hormone produced by the ovaries, placenta, and adrenal glands. It not only is involved in the menstrual cycle, female sexual development, and pregnancy, but it also plays a major role in the development of cortisol (one of the body's stress hormones).

I am going to skip over progesterone's role in pregnancy: I figure that the detailed labor and delivery post covered enough of the fear factor that I don't want to re-engage the post-traumatic stress in by mentioning the physiology of pregnancy. I know, the flashbacks were horrific. ;).

Other effects of progesterone:

Involved in synthesis of fat into energy (It's one of "The Biggest Loser" hormones.)

Participates in blood clotting

Acts as a diuretic. (No progesterone and you bloat up like the Stay-puft Marshmellow Man.)

Stimulates bone building, thus preventing osteoporosis

Helps regulate blood sugar levels

Acts on oxygen levels in cells

It's part antidepressant on its mother's side.

What are some of the expected levels of progesterone?
This is when you hijack a medical lab and ask them to take your blood progesterone level. Or you could always visit your health professional and have them check your level for you, but where's the fun in that.

Reproductive years: 8-10 ng/ml

Menopause (lows): 0.1-8 ng/ml

Menopause (highs): 10-16 ng/ml

Post-menopause: 1 ng/ml

Durning pregancy: 16 ng/ml

Normal ovulation: 20 ng/ml
(Image and data from www.natural-hormones.net ; and Speroff, et al. (1989). Clinical Gynecologic Endocrinology and Infertility. 4th ed. Baltimore: Williams & Wilkins.)

And why do we care about the stupid numbers? Well, WE don't. But it's those psycho anal physicians that are so addicted to numbers, that we have to feed them lab results at least once or twice a week in order to prevent them from having withdrawl symptoms.

Either that or those mad scientists with data fetishes. Sometimes, I can't tell which. (Image from http://www.arronbailiss.co.uk/).

Down on Your Luck: Low Levels of Progesterone

Symptoms of low progesterone are those that involve the men running sreaming and the women wanting to beat the living tar out of them. Either the woman's progesterone is low or the man was caught cheating. Either way the woman is irritable, sweaty, and ready to break something.

Low Progesterone Signs and Symptoms:

Irritability
PMS/ Mood swings
Difficulty concentrating
Memory deficiencies: memory loss, lack of mental acuity, brain fog which is not to be confused with brain freeze. That is derived from drinking huge amounts of Slushies too fast. [And yes, if you were wondering, low hormones have been linked to Alzheimer's disease*. ]
Insomnia
Hot flashes/ Night sweats
Anxiety/ panic attacks
Depression
Irregularity of menstrual cycle
Abnormal/ excessive uterine bleeding
Uterine fibroids
Uterine cancer
Strong cramps during menustration
Greater presence of blood clots during menstruation
Vaginal dryness/ irritation
Joint pain/ muscle pain
Breast tenderness
Frequent urinary tract infections
Headaches, Dizziness
Weight gain
Edema /bloating (water retention)
Fatigue
Dry skin
Low blood sugar levels
Deficiency of Magnesium ( This kind of has the chicken vs the egg dilema about it.)
Thyroid malfunction
Gallbladder disease
Infertility/ difficulty with conception
Lack of libido (Men tend to mourn this aspect.)

I do have to state here that low thyroid (or hypothyroidism) can mimic many of the signs and symptoms of low progesterone and vice versa. It is especially important that you contact your healthcare provider when you experience any of the above.

Granted, in the case of dizziness, fatigue, and headache, these symptoms are very ambiguous for medical practitioners. They are like the needle-in-the-haystack: You have the needle, but now you have to figure out which haystack it was in and how it got there.

In my next post, some natural and medical methods of relieving the symptoms of low progesterone will be discussed.

References list:
*Carroll, J.C., et al. (2007). Progesterone and estrogen regulate Alzheimer-like neuropathology in female 3xTg-AD mice. The Journal of Neuroscience, 48: 13357-13365.

Simpkins, J.W., et al. (1997). Role of estrogen replacement therapy in memory enhancement and the prevention of neuronal loss associated with Alzheimer's disease. The American Journal of Medicine, 103:19S-25S.

Vongler, J.M and Frye, C.A. (1999). Progesterone in Conjunction with estradiol has neuroprotective effects in an animal model of neurdegeneration. Pharmacology Biochemistry and Behavior, 64: 777-785.

Other links regarding low progesterone:

http://www.diagnose-me.com/cond/C8779.html

http://www.tarunaoils.com/articles/low-progesterone-levels-signs-symptoms.asp

Mandrakes, Mallots, Malts: Natural Anesthetics?

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Tue, 13 Jul 2010 20:11:00 +0000

Okay, I am writing two separate posts at the same time. Do you realize how brain fogging that is? ;) It's like listening to a bunch of Irishmen after they downed 20 Guinness, while eating snapper candy. It just shouldn't be done. ;)

Just for fun, I want to state here a few of my favorite questions:

Why are most politicians evil? Because in the job description it says, "several years of experience in evil-doing, lying, cheating, and stealing required for employment in this position". ;)

Why are evil dark overlords politicians in training? Because everyone has to have retirement plans. See required politician experiences.

What do storm troopers wear under their uniforms? Smiley face boxers and t-shirts that say "I love carebears." It's totally obvious. (image taken from http://www.shutterpoint.com/Photos-ViewPhoto.cfm?id=184251)

But the question of the day is:

What are some natural anesthetics? This was the great inquiry made by a wonderful blog follower that I decided to write this post in response to. (I'm biased: I love my blog followers.)

So let's start with a little medical history. Okay, I think I just lost half of my viewers with the "history" comment.

Historical Natural Anesthetics:

Now, I am not an expert on the natural ways of numbing, so I grabbed my knapsack, couple of bottles of generic filtered tap water that I was charged a buck a piece for, and went on an epic journey to research natural pain killers. [First, I looked at historical analgesics. You know, there is something to be said about some wives' tales: just not the ones that told knights that they needed to be sewn into their armor for good luck. Funny, but so wrong on so many levels.]

Anyway, after that search, I discovered many things. One, Harry Potter was right: people did actually believe that mandrake plants killed you with their screams. (Please enjoy this refresher video of Mandrakes. Mandrake - Harry Potter and The Chamber of Secerets).

And two, our ancestor's were whacked out of their gord.

I am not kidding, this is the first time that I can honestly say, "what the heck were our ancestors were thinking?!"

Seriously, I wonder how any of them survived long enough to create the next generation.

Most of the "numbing methods" they applied centered around doping themselves up enough hallucinogens to ride magic carpets (now, we know why they have those freaky fairy tales), hitting each other in the head with massive hammers, downing keggers of beer, and eating plants that are lethal.

Well, that explains a lot of historical events.

Hitler being voted in. Definitely a bunch of people on natural pain drugs. The voter cards looked blurry under the flying spots and fairies. They mistook Hitler for "hit here." (Actually, "hier" in German, but eh, details, details.)

The Third Crusade. It was all in the mead. Who else but drunks would head into the hottest, nastiest area of the world wearing heavy armor and start a war?

Atlantis. They took the Bugs Bunny approach to numbing methods and beat each over the head with mallots, then became lunatics thinking they could take over the world. Why else did God send their island into the ocean?

Easter Island. Self-explanatory. The entire population ate their weight in lethal mandrakes.

At any rate, the ancient methods for pain reduction were in fact:

1. Halluciongenics such as opium, and cocaine
2. Alcohol (largely whiskey and wine)
3. Striking the patient in the head (either by placing a helmet over the person's head and hitting them with a mallot or by giving them a good punch to the jaw. They lost a couple teeth, but hey, they were unconscious during surgery).
4. Mandrakes (a potentially lethal plant from the nightshade family)

Well, we can't knock them for trying. In all honesty, we pretty much use the a few of the same things for pain relief.

The analgesics Lortab and Vicodin are semi-synthetic derivatives of the opioid family. (Codeine and thebaine are two of the naturally occurring opiates used in the creation of these drugs.)

And come on, I know there are a few of you out there that wanted to deck that guy that was screaming in pain. (Please see reasons why not to go into medicine).

Anyway, let's discuss mandrakes (Mandragora officinarum). These are members of the nightshade plant family (Solanaceae) and genus Mandragora. [Included in the nightshade family are potatoes, tomatoes, peppers, and eggplant.]

The genus Mandragora, on the other hand, realistically should be included in the hallucinogens category, but I want to give them their own attention.

The mandrake contains alkaloids such as scopolamine, atropine, and hyoscyamine. These are potentially deadly substances. So it wasn't the screaming that killed them, it was the alkaloids.

Atropine is used as a treatment for organophosphate poisoning (pesticides) and used to resuscitate patients with severe bradycardia. (For more information see: http://www.cvpharmacology.com/antiarrhy/atropine.htm and http://en.wikipedia.org/wiki/Atropine).

Not only are the Mandragora potentially deadly, they actually promote inflammation and pain. They produce a number of alkaloid chemicals that can range from irritating to lethal.

So why am I telling you this? What is this historical lesson good for?

One, our ancestors were a bunch of neanderthals when it came to medicine. But... although crude, the doping, drinking, and clobbering approaches, were actually affective.

Two, mandrakes, instead of being used for pain relief, can be used to treat organophosphate poisoning which is a life-threatening condition.

Three, for chronic pain or headache suffers, avoiding the nightshade family altogether (tomatoes, potatoes [especially the green and sprouted spots on potatoes], sweet and hot peppers, eggplant, tomatillos, tamarios, pepinos, pimentos, and paprika), actually does help lessen chronic pain symptoms. (For more information please see http://www.whfoods.com/genpage.php?tname=george&dbid=62. and see also, http://naturalmedicine.suite101.com/article.cfm/nightshades)

Lastly, I am still looking for natural anesthetics that are safe and available for disaster medicine kits. Sorry. I wish I could have found something more helpful. Apparently, the best things that we can store up are the prescription analgesics and local anesthetics.

So far, I have been unable to find any natural ones that have been scientifically proven to be safe and to actually work. For the sake of my viewers, I will keep looking.

TTFN.

Wound Closure: Up-close and Personal

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Tue, 22 Jun 2010 16:11:00 +0000

Okay, so I have been ditching my posting duties. It has been a few months and you haven't heard one lick from me. I know, I know. You were wondering if I was abducted by aliens. Well, they did land in my backyard: I offered them lemonade, and sent them on their way, but inadvertently, no abductions. (Image taken from http://noliesradio.org/archives/1954)

Sorry, I know you're disappointed: I have no alien anal probe experiences to share, but I can tell you about a lot of colonoscopies I have assisted in if you're interested. Man, there were some colons that would reek so bad that--. Wait, you want me to talk about wound closure instead? Are you sure? I mean I can really give you a riveting story about the day that the Sick Colon Struck Back.

Oh, alright. Fine. Be that way. See if I ever tell you about colons again. ;)

Wound Care: Anesthesia

Since we have past the medieval ages, we have ways of numbing wounds. When I was looking up videos for lidocaine injections, I found a great site that gave the following list of subjects:

1. Inject insulin
2. Inject local anesthetic into a wound
3. Pick locks with a strategically placed bump key
4. Prepare an insulin syringe to inject a diabetic cat.
(Image derived from http://www.watercure2.org/pet_testimonials.htm)

Yes, that is the actual list. Hmmm, so let's ask: which of these doesn't belong? The picking locks or the diabetic cat? I think I will go with the cat. (please see: http://www.wonderhowto.com/topic/inject-lidocaine/). (Image taken from http://thegreatgeekmanual.com/blog/motivational-poster-lock-picking)

Back to the blog at hand: Last time we discussed wound irrigation and the different types of antiseptics. So I am going to leave that out of this discussion, except to say: Please irrigate and clean the wound before administering anesthetic.

Okay. Okay. There are a bunch of whiners out there that couldn't handle a wound cleaning if their life depended on it. So in their case, just sterilize your injection site first then give the local anesthetic then clean them. Whine whine complain.

But for everyone else:

1. Irrigate

2. Clean

3. Prep the area with an antiseptic.

4. Prepare a 27 or 30-gauge STERILE UNUSED needle synringe with around 3 cc of anesthetic. (Wipe the top of the anesthetic bottle with alcohol pad before inserting the needle. Draw out 3 cc or more solution.)

5. Infiltrate the skin (epidermis) at the edge of the wound with the needle bevel side up.

6. Create a skin wheal by slowly injecting approximately 0.5 cc of anesthetic into the area. (Note: To all the trigger fingers out there, refrain from turning the injection into a Nascar race. Rapid injection produces painful swelling of the tissues.)

7. Redirect the needle within the wheal if needed. Once the first wheal is created, you can always redirect the needle within it towards a different direction and add an additional 1 cc of local into the dermis. If needing to re-enter the skin for further injections, try to re-enter a site that is already blanched or part of the wheel you made previously. This will prevent further pain, because you will be entering a site that is more likely to be numb.

8. Go get a hamburger. Enjoy a good movie. No, just kidding, but you can afford to wait a couple minutes for the anesthetic to take affect. A good injection will leave a thick wheal line around the edges of the wound and take into account its depth.

9. Gently poke the wound area that you intend to suture with a sterile needle (you can use the one you injected them with). Now, this doesn't mean go for the gold and poke 'em like you mean it. Gently means gently.

The patient should feel pressure but nothing sharp. If they feel something sharp, one they may slug you; and two, you need to add more local to the area.

Anyway, I promised you that I would discuss lidocaine. Truthfully, I thought about running to South America before giving the lidocaine interview, but alas, the border patrol saw I was an Amercan with out papers and I got deported. :)

Lidocaine vs. Bupivicaine

This is the "Tastes great. Less filling" debate of wound care. You may see the anesthetic protests and WWF smackdowns at a local hospital if you are lucky. I think I saw a surgeon take out an ER doc over this once.

These two are the most commonly used local anesthetics. Lidocaine being the very most common. In fact, it is widely used for the majority of cases, but Bupivicaine is used in situations that needed a longer duration of coverage. Those type of situations generally involve complex wounds that would require a greater amount of time to close.

I have been known to make a Lidocaine-Bupivicaine cocktail. Mix in a little epinephrine and some Sodium Bicarbonate and my patients love it. Shaken not stirred.

Lidocaine with epinephrine (the most popular, kind of like the Homecoming Queen of anesthetics) generally lasts 2-6 hours.

Bupivacaine (Marcaine) with epinephrine generally lasts anywhere from 3 hours to 7 hours.

Note: if you want to be nice to your patient and you have it on stock, add some Sodium bicarbonate to the mixture. You just draw enough Sodium bicarb to cause the clear solution to turn cloudy. That is the chemical reaction of the Sodium bicarb neutralizing the acidity of the anesthetic, thus relieving the burning sensation of the acidic local.

So, let's take the ' why epinephrine?' quiz:

Why do you want to include epinephrine?

A. Because the pharmaceutical companies told you so.

B. It blanches the skin, helping you to better identify which areas that have been numbed.

C. Because it decreases bleeding. Nothing says, blood go away like epinephrine.

D. It increases the maximum dose of local you can apply to the area. It vasoconstricts blood vessels thus preventing systemic absorption of the anesthetic.

E. All of the above.

F. B,C, D and forget about A

The answer is F. Sorry to all those that chose A. I know, you were tempted to break down the pharmaceutical company doors for forcing you to add epinephrine to local anesthetics, but we must refrain.

When considering whether or not to use a mixture with epinephrine in it, please remember one important rule:

Epinephrine should NEVER be used in the following areas: Ears, Nose, Fingers, Toes and male anatomical parts.

Top Five reasons why you don't want systemic absorption of lidocaine:

1. Wastes lidocaine. Hello, you're in the middle of a disaster. Is the pharmacy going to be open. ;)

2. Aliens don't approve.

3. Your mother told you not to.

4. Because the cows might attack. Udderly terrifying. (Image taken from http://www.robmillard.com/archives/cat-off-the-wall-insights.html)

5. Lidocaine is used to treat disturbances in heart rhythms and can stop a normal working heart.

I don't know, I think number 4 is the most important. ;) Those cows can be dangerous.

Interestingly enough, lidocaine decreases the sensitivity of cardiac muscle to electrical impulses. No. We don't want insensitive hearts. We need sensitive hearts to cry, to love, and to live.

Lidocaine acts by slowing the conduction of electrical signals within heart muscle. Thus, it helps restore the heart's rhythm in conditions such as irregular and incresed contraction of the ventricles (ventricular tachyarrhythmias). (please see http://www.netdoctor.co.uk/medicines/100001501.html for more information on lidocaine and heart arrythmias, and also http://en.wikipedia.org/wiki/Lidocaine)

Here are a few good sites providing more information on anesthetics:

Local Anesthetic

How Anesthetics work and their History

Why you shouldn't go Butt-crazy in administering local anesthetics

The following are some really great videos further explaining the administration of local into a wound as well as the basics of suturing. Yes, I'm being lazy. If there is a good video out on the subject, why should I have to write it? Besides, the aliens say no more writing until the mind probe is activated.

So until next time. TTFN.

Injecting a local anesthetic into a wound:

Basic Suture Technique:

Suture Technique Part 2

There is More Than One Way To Sterilize a Wound

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 20 Mar 2010 20:00:00 +0000

I know. I know. If I steer away from the beloved alcohol post, you won't be able to enjoy the bitter beer face anymore. Don't cry, moving on is an important part of life.

Yes, the sensational appeal of an old scary man bringing his bottom lip up high enough to swallow his whole head just brings tears to our eyes, but... No more beer for you! ;)

Since, alcohol is such a volatile substance to be pouring on any wound, I'm going to move to more gentler and practical means of sterilizing and cleaning wounds.

Cleaning wounds:

Everyone loves having their wounds cleaned, especially when we have to take a wire scrubbing brush to them just to clean out the debris and dirt.

In a different post, I will discuss the need for analgesics and the favorite question of how to administer lidocaine. Although, if you were wondering, it would be good to have 1% Lidocaine and topical Lidocaine gel in your trauma kit. Otherwise, your patient, if they are still conscious when you start messing with their wound is going to beat you like a red-headed stepchild in a drunk family.

So moving on to wound irrigation and cleaning. I, personally have a dozen lactate ringers, three dozen normal salines, and a bunch of contact lens cleaner (works just as good) in my personal kit for wound irrigation. But I like irrigating wounds, it's fun to watch big chunks of crap fly out an open wound to hit your assistant.

Rule one of proper wound irrigation: Aim the irrigation so that it sprays and hits your partner. It never gets old.

Tap water also can be used to clean a wound as long as there has been no earthquake or radiation in the area. Tap water is obviously not as good as sterile saline, but oh, well... if you're not a wound cleaning junkie like me, then you might not have the solutions on hand.

But just for the heck of it, a good home solution for wound cleaning is tap water and Johnson & Johnson Baby Shampoo.

People always ask me about Hydrogen Peroxide (H2O2) in connection with it being an antiseptic, because they see it a lot be mixed with water and used to flush out some wounds, especially things within the ear. It's a good cleaner, just as water is a good cleaner.

Yet, unfortunately, H2O2 isn't that great as an antiseptic, because it has only minimal bactericidal effects, especially the dilutions of less than 3%, but it does make cleaning the infection funner... ahem, I meant easier.

Ever wondered why hydrogen peroxide foams: Cells contain an enzyme known as catalase, which floats around in wounds and also many bacteria are catalase formers. When catalase and peroxide come in contact with each other, they react to form water (H2O) and Oxygen (O2). The bubbles that you see are oxygen being released from the liquid.

A good way to test this is to put hydrogen peroxide on a cut potato. Cut potatoes are rich in catalse.

So all in all, it really doesn't do jack, but watching it bubble makes us feel better.

So you clean the wound by hosing it down with enough saline to hydrate a dehydrated camel (yes, they too can get dehydrated), and remove all of the debris.

Anyway back to the real reason why I wrote this post: Antiseptics.

There are many great antiseptics out on the market today, most of which have been tried and tested in clinical studies.

According to the Wound Health Society, the best antiseptics would be Chlorhexidine, Cadexomer iodine, Ethacridine Lactate, Polyhexanide, and Betadine (which is 10% Provodine Iodine).

I prefer Cadexomer then Chlorhexidine then Ethacridine (for topical wounds) and Polyhexanide (name brand is Pronotosan, and is good for wound cleansing). The effects of betadine are not lasting and it has to be applied without re-introducing more bacteria to the area. (Note: On the other hand, the shelf life of betadine is one of the longest.)

I want to add to this list also a gentle antiseptic benzethonium chloride which is a great antibacterial solution for children that can be also used as a hand sanitizer. (Note: alcohol based hand sanitizers can be used as well for would disinfection, but like the regular alcohol: they will burn like a Biggest Loser workout.)

Benzethonium Chloride can be found in products from a company called Pureworks. www.buypureworks.com.

On the natural end of things, I would say 10% Calendula officinalis (pot marigold) and Manuka Honey.

Here are a couple links scientifically comparing many of the different types of antiseptics and wound treatments, just for the fun of it:

Antiseptics on Wounds, Part 1

Antiseptics on Wounds, Part 2

Emerging Treatments in Diabetic Wound Care

What? You thought I would write more? Eh, I'm being lazy today.

But I will leave you with this wonderful add put out by some very well meaning individuals. Enjoy:

To Booze or Not To Booze: Alcohol as an Antiseptic

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sun, 07 Mar 2010 16:00:00 +0000

Disclaimer: I am not promoting the drinking of alcohol: I personally think it is devil's urine. The stuff eats through livers like the government does tax payer dollars. (Image taken from: myrightword.blogspot.com)

Yet, there have been many questions concerning alcohol being used as a wound antiseptic. So, I thought this might be a good subject to post on. (To all my American Preppers followers, I have already posted the majority of this under the Little Doc section).

Myth Busters: Alcohol and Wounds

There are better forms of disinfection than cracking out a cocktail, but to some extent, it is true that certain liquors do in fact treat wound infections. They burn like a monkey beating, but they do work. (Image taken from: Closebutsofar.com).

It is true, there have been actual cases where men have been mauled and bitten by wild animals, such as bears, and icing them with Toddy saved their lives. So it is definitely not a myth that spirits saves lives.

[Man, can you believe this kung-fu-monkey kicking the crap out of that guy? It's seriously giving him a Jackie Chan smackdown. Like a Chuck Norris chimp kind of thing.

So, I'm assuming that the guy might have needed some antiseptic after that punk-slapping.]

Anyway, while in the field and there is no other source of disinfectant available, liquor is a great alternative to field water. Granted, your buddy will want to kill you as you pour that firewater on his open wound, but think on the bright side... he's injured and you can run faster.

There is one problem though. Alcohol can, unfortunately, work too well and cause tissue damage due to its ability to penetrate and lyse cells. Hence, the reason for its effectiveness against bacteria.

You pour moonshine on an open wound... bye bye bacteria, but also many good cells go down with it. It's like Rambo saying, "I'm taking you all down! And your little dog too!"

The 'Proof' is in the Pudding.

Anyway, on a more scientific note, it is the alcohol content that determines the hooch's antiseptic abilities.

When you see an old drunk in a western movie down some diesel fuel and make a face like he's dying. Then he chokes out a barely audible gasp with satisfied smile, "Now, that's the good stuff." You know he's talking about at least 35% alcohol by volume (ABV) or 70% proof. See and you thought old westerns weren't scientific.

And that type of liquor is the "good stuff"

In order to cleanse a wound, the drink must be at least 35% alcohol (ETOH) or it's disinfecting capabilities are practically nil. Not at least 35% ABV then you might as well pour apple juice on the wound.

Anyway, let's see how some sauce's measure up:

Beer 3-12% ABV. Sorry guys, your beer isn't worth Jack.

Wine 9-16% ABV. Ladies, the romantic films where the woman pours a bottle of wine on her dying hero's wound to save his life, are liars! Woman pours wine. The bacteria remain and cause sepsis. Hero dies, end of story.

Next!

Fortified wines. (aka port, madeira, sherry, etc.) 15.5-20% ABV. Only good for cooking.
Brandy 36-60% ABV. Brandy does well against infections.

Pure vanilla extract. The poor man's ponto. >35% ABV. What do you know! You can totally sterilize a wound and smell like vanilla at the same time.

Vodka. I understand the Nazi German's used this substance to turn Russian prisoners into human flame throwers. Yikes.

Is it potent crap? Rating in at 32-80% ABV, yes it is! (Pure Russian brands coming in at closer to 80%... Go Russians, they can sterilize wounds and kill livers at the same time.

Rum and Gin 40-80% ABV.

Whisky. 40-55% ABV. Like you were expecting Whisky to score lower.

Raki. 42-86% ABV. I have never heard of this paint before. I wonder if it is related to Saki, on it's mother's side?

Poten. 60-95% ABV. I love this one's name, especially because it is one of the most potent.

Neutral grain spirit or moonshine 95% ABV. We have a winner. That's practically ethyl alcohol! It might as well be sold in the pharmacy section of Walmart with a sign on it saying, "Moonshine, it's medical grade."

So now all you have to do is open up moonshine businesses in your back yards and when the cops come to bust you, you can tell them that you're running a medical supplies company specializing in antiseptics.

One more word of warning: Do NOT drink and clean wounds at the same time. None of that: "One for the wound, one drink for me. One shot for the wound, two shots for me." Not good. Bad idea.

And remember, "Friends don't let friends drink and do wound care."

The next post will be about better and more appropriate wound antiseptics. TTFN

Here is the site of today:

General Wound care

Just for he heck of it, here are a few more monkey pictures, from zomporo.com and everydaynodayoff.com.

This one is just too funny. Scary, but funny. I think this monkey was ripping the guy a new one one about wound care and booze.

And I couldn't help, but go "awww how cute!" when seeing this picture from EverydayNoDayOff.com.

Superglue: It Burns Us! It Burns Us!

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Thu, 04 Mar 2010 21:24:00 +0000

It is amazing how mankind strives for the unattainable treasure, works for the impossible dream, labors to overcome all obstacles... Wait, who am I kidding, we look for the easy way out.

It's all about convenience. Heck everything has a drive through nowadays. Fast food, pharmacies, grocery stores, weddings in Vegas. Yeah, it's true: you don't even have to get out of your car to say your "I do"s. See: Convenient.

It all started back when some misguided, drunk aliens crash landed their UFOs on Earth and mixed their genes within society, creating a techno-savvy but lazy generation that doesn't care about the consequences as long as the effort is minimal and the execution is fast. ;) It also explains why a vast majority of people drink enough alcohol to kill their livers, but that's another story.

Don't worry: the well-paid government scientists in Area 51 are working hard to this day to find a cure for the laziness gene. Unfortunately their efforts are thwarted by undercover aliens who created the Clapper, remote controls, those reaching sticks with the pinchers on the end, and superglue.

And as we all well know: the easy way is not always is the best way.

Fast food. Result: Coronary artery Disease.

The Clapper. Result: A bigger pant size and annoyed spouses.

That hot dog stand on the side of the road. Result: A bacteria so vicious that it beats your insides with a mace.

Superglue. Result: A myth about its use in wound care.

The highly classified alien project superglue leaked out of Area 51 because some punk paid off a guard, and the glue landed in the hands of medical personnel in the Vietnam War.

Medic 1: "Now that's a biggin'! I don't want to suture wound. What about you, Bob?"

Medic 2: "Nope, too much work. Heck, with all the gunfire raining down over our heads, who has the time. But, look I've got some alien superglue."

Hence the discovery of superglue for wounds.

Seriously though, during the Vietnam war, medics did find that superglue was made of a substance called Cyanoacrylate, which made a great wound adhesive. When the substance comes in contact with liquids, it forms a plastic mesh, thus sealing off wounds.

Now, I can really see the benefit of sealing up a wound at lightning speed, especially when bullets and mortars are your surgical background music. But over a time, they discovered that superglue had some side effects and decided that it shouldn't be used all the time. Unfrotunately, the rest of society are struggling with the lazy gene and believe superglue is good for everything.

When it comes to wound care, my little three year old niece believes that the only cure to anything is to put a band-aid on it. You scrape your knee; put a band-aid on it. You bump your head; put a band-aid on it. You fall down the stairs; put a band-aid on it. You knock your car bumper off by hitting that trash can that came out of nowhere; put a band-aid on it.

And now, superglue has become the 21st century prepper's* version of the "band-aid." I don't think I have heard of a disaster preparedness kit yet, that doesn't have superglue in it attached to the belief that one can put superglue on pretty much any type of wound that needs suturing.

I hate being a myth buster. I love myths. The myth about a dorky nerd flying on Pegasus to chop the head off a chick so ugly that looking at her turns you to stone is a great myth... that I can believe. But the myth about superglue being a great wound adhesive is just going too far.

The superglues out on the market today also contain a chemical called methyl alcohol, which releases energy in the form of heat during the formation of the adhesive. Therefore, because of this exothermic reaction, the good periwound tissue receives a chemical burn that destroys the granulation buds, thus preventing correct wound healing.

I figure this is what happened when Golum started screaming, "It burns us! It burns us!"

What you didn't see was that in a earlier edited scene Golum fell on his buck-naked butt, getting a wound the size of Gibraltor on his scrawny cheek.

Then a wise guy said, "Let's put superglue on it." That's when you see Golum running around, "It burns us! It burns us!" It's in the unofficial director's cut.

To prevent this chemical burn a medical grade superglue (tissue glue) that it is also a form of cyanoacrylate has been developed. This glue has no exothermic reaction and has added ingredients possessing bacteriocidal effects, such as either butyl, octyl, or isobutyl derivatives.

Now, I'm not saying that you have to dig through your gia-normous, end of the world trauma kit and throw out your superglue. You can still use it, if you don't mind the burning sensation...

Provided you follow a few simple rules:

NEVER use superglue on a wound that is deep into the body... seriously bad idea to chemical burn deep tissue. Healing will be delayed on a whole new level.
Don't glue your finger to your patient. That's not good in the wilderness. It can be laughed at in the hospital, but in the wilderness, you might end up pulling a Coyote Ugly.

The Minor Leagues are better. If you are going to use superglue to close a wound, you should probably use it on a minor wound that is straight and of which the skin flaps easily close back together.

Well, I better end my blogging for today. TTFN.

If you have any further questions, please feel free to email me or post a comment.

*Prepper: Person involved in preparedness.

Blood, Guts, and No Worries: Woundcare in the Wild

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Fri, 26 Feb 2010 21:00:00 +0000

In the event of a zombie attack... wait, oh, that's right, there are no zombies attacking these days. Just the Taliban. ;) Seriously though, have you noticed that there are a good number of zombie attack preparedness sites out there in blogger space?

I mean come on ...they're slow and falling apart like my uncle's Chevy. That thing can't even get out of the driveway without losing it's oil pan. I'd be more afraid if there was an attack of rabid old people: they have canes. And they can spit their dentures out at you from a mile away. Think about it, their walkers scraping the ground as they stalk towards you, mole hairs waving in the wind. Some carrying rolling pins, shouting, "In my day we didn't have internet!" Now that's scary.

But whatever slow moving decrepit thing, whether it be zombies or rabid fossils, is attacking in the apocalypse, you need to prepared. Dude, but if you can't out run either of them, you deserve getting bit.

Now I can't train you to fight off a zombie, but I can teach you how to handle wound care in the wilderness. I can't tell you how happy I am to finally get to the wound care series of these posts.

I couldn't wait to post this so much that I have already posted some of this on a wonderful site, called American preppers. So to all my Preppers buddies: Sorry for the repeat.

First Aid on the Frontline

In all medical situations, even those within the hospital setting, any medical professional must act according to a certain order of important principles because of their lifesaving nature.... the ABCs.

A - Airway
B - Breathing
C - Circulation
D - Disability

Airway: Basically, you make sure that they have an open trachea (windpipe) or an open way to breathe. No open airway: No way they can breathe. (Image taken from: California White Water Rafting and First Aid. This is a site specializing in training wilderness medicine hands-on.)

Breathing: You look, listen, and feel for their breathing. This is also where rescue breathing comes in. Give two breaths. Refer to Rescue Breathing Video.

Circulation: The bleeding. Here is where you treat the wounds. You wait until you know that they have an open airway and are breathing before even attempting to take care of their bleeding.

Handling their airway and breathing can be quite simple in many circumstances. If they are screaming, talking, complaining, or swearing at you like they're a drunken sailor than they have an open airway and they are breathing. See. Simple.

Disability: This step is where you check to see if they can move all four extremities and splint broken bones. If they are waving a bird at you, then they can move that extremity.

Now for the good stuff...

Blood, Guts, and Gore...

Okay, so only a little blood, no guts, and well, the gore is up to your perspective.

When faced with wounds, there are a few goals that you need to focus on, especially out in the boonies.

1. Control the Bleeding: The whole point of the Circulation portion of the ABCs.
2. Clean the wound and prevent infection
3. Reduce discomfort and promote healing
4. Minimize the loss of function (we're dipping into the disability stage here, but still we need to mention it.)
5. Perform correct care and transport of patient

Before I get into the nuances of wound care, I would like to stress here that you need to attempt some form of body-substance-isolation (BSI) first. BSI is a full body cover-up kit. And I seriously doubt that any of you are carrying a surgeon's gown mask, and surgeon's gloves in your backpack. So let's make one with stuff you might be already wearing.

Eye cover: Ski goggles or sunglasses or even regular glasses (not as great as those ski goggles, but hey, it's coverage).

Gloves: Any water barrier gloves or barrier material, such as those Ziploc sandwich bags your PBJ is sitting in, or the plastic grocery bag that you are carrying to put your trash in.

Body cover: Because some of these wounds can make Old Faithful look like a weak geyser. Parka. Ski Jacket. Big garbage bag with holes for arms. Or that "Kiss the Cook" apron works too.

Alright, you're covered up and you throw a tarp down for your poor bleeding patient to lay on.

Now you're ready to deal with the Slasher flick before you.

CONTROL BLEEDING

How do we control bleeding? Pressure. Pressure. Pressure.
Literally, you apply pressure to the wound. Get your gloves in there, if you don't have gauze, and apply some direct pressure to the wound. (Be one with the oozing wound... Ohmmmm).

Direct pressure, elevation of the body part, and packing with a moist sterile dressing or clean cloth (if sterile is unavailable) will stop most hemorrhaging.

I, personally, like to add to my wilderness kit a little hemostatic qauze or agents like Celox, Gelfoam, Surgicel, or Jello (non-sterile)... there's always room for Jello. These speed up the clotting process considerably.

Stop the bleeding and pad with sterile gauze or clean cloth... or you could even use one of your Ziploc sandwich bags minus the PBJ to dress the wound... than affix it with roller gauze, surgical tape, or that duct tape that you know you tie around your ski poles or walking sticks. Duct tape is your friend.

CLEAN WOUND AND PREVENT INFECTION

Irrigation is more than just a farming tool. Basically, you take sterile water and spritz down the wound, washing debris, soil, foreign bodies, etc from the wound. Well, you forgot to shove that liter of sterile fluid in your backpack, but you do have your sports water bottle or canteen.

Remember your goggles... they come in handy right at this point. You spritz them, they spritz back.

In situations where you don't have irrigation available, use a ziploc bag filled with clean water, put a pin-sized hole in it, and spray the wound clean.

Visible debris can be removed with sterile forceps or if you don't have them, tweezers dipped in alcohol.

You know, also contact eye solution can be used to irrigate a wound. Not only is it a clean isotonic solution, but it also has some minor elements of bacteriocides within it.

You can use honey or sugar as a natural antiseptic. Except with the honey, avoid putting the honey on the good intact skin, just put it in the wound then cover it with a sterile or clean dressing. With the sugar, just pour it in. Your patients will say that you're sweet for treating them so wonderfully. I will discuss the benefits of honey later in a different post.

REDUCE DISCOMFORT

There's more to do than just knock them out with a tree log.
Stabilize the extremity with the wound. Strips of duct tape can be used to close a wound in place of steri-strips if you don't have them on hand. Dermabound and its non-sterile cousin, tissue glue can work as well. Be careful with super glue... it can cause chemical burns. (I will discuss superglue in a different post.)

PERFORM CORRECT CARE AND TRANSPORT

Lastly, if it's wounded, get rid of it. No, you don't shoot them... although there are some whiners out there that might tempt you to do so.

Seriously, if a person has been wounded, evacuate them. They need to get proper medical care.

The following is a list of "wound" situations where evacuation of the patient should be as rapid as possible:

-Infected wounds, deep penetrating wounds, impaled objects, wounds with ligaments, joints, tendons, or bones exposed

-Animal or human bites. (Yes, human bites can happen. Some people get awful hungry in the wilderness.)

-Severe blood loss

Next time, we will talk about using natural antiseptics.

TTFN.

If you have any further questions, feel free to email me or post a comment and I will get back to you as soon as I can.

(UPDATE: I do want to thank a reader that has enlightened me on my typos. Remind me never to speed through a blog without grammar checking it first. ;).

Also, I have been informed that there are an epidemic of "fast zombies"... I would have thought those were medical students rushing of campus after a week of exams, but apparently, there are other types of fast zombies.

I would like to express my appreciation for the reader that helped me realize all this. Thank you :). )

Don't Know Jack Forst: How to Handle Hypothermia

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Thu, 25 Feb 2010 20:04:00 +0000

You know I have been debating whether or not to write more about hypothermia. It has no guts, no glory, no raving zombies you have to fight off. It is just Jack Frost taking a chunk out of your hiney then calling it a day. What kind of criminal locks a person in a refrigerator and just leaves whistling like Frosty the Snowman? The boring kind, that's who.

See that's why I like writing about wilderness wound care. Because no bear smacks you upside the head then leaves; they finish you off. Then gnaw on you for a few more days. Now, that's civil.

But mean old Jack, he just sits there on his cold-hearted balloon-knot and blows frosty mist in your face. But we, weak, mortal non-mutated humans tremble under his ice cold breath. (We shiver.) Then being the rough and tough rumbler John Wayne-wannabees, we still get in Jack's face and say, "You want a peice of me, you icy beast-ard!" (We get irritable.)

And of course, we dance around like Mohammid Ali with butterflies in our pants. By this time we're looking like insane bunnies on crack. (We start to get an altered mental status.) Jack just sits there and yawns. He's got all winter. But sooner or later Jack tires of us and gives us the cold shoulder, so we freeze into a human-sicles, and he leaves. (That's when spring comes and some park ranger finds a defrosting human-sicle in the wilderness.) That's it. Where's the excitement in that?

So, I thought long and hard about this, contemplating the universe without zombies but instead with frost bite. Yes, the debate was heartfelt. It lasted all of but three seconds. So here I am writing more on hypothermia.

The Three Stages of Defeat:

When God created Adam and Eve, and they were naked in the Garden of Eden... God make heck of sure that the temperature was an ambient 72-74 degrees fahrenheit, otherwise we would have had two frostbitten first parents. The human body is designed to handle moderate temperatures being bare-buck-naked, and Heavenly Father knew that. Life was paradise before that nappy serpent introduced the forbidden fruit. Stupid snake.

Now, being in the lone and dreary world, we have to bundle up or our core body temperature drops fast... because not every day is going to be paradise. (If you're in medical school, than no day is paradise... because you're living in a literal hell. ;).)

Mild Hypothermia

This starts when the body's core temperature drops below 95 degrees fahrenheit (35 degrees Celsius), but is still above 90 degrees.

This is where we start shivering, our extremities become numb, and we experience a reduction in manual dexterity. Remember the last post: 'drop of 1 degree Celsius' and we turn into 'mean drunks'? Well, here we are. Mean shivering drunks. Complex skills become difficult. We become tired, can't throw a snowball to save our lives, and forget about cooperating with anything or anyone.

Here's a mnemonic device developed by Giesbrecht and Wilkerson in their book, "Hypothermia, Frostbite, and Other Cold Injuries":

Fumbles
Stumbles
Tumbles
Mumbles
Grumbles

Moderate Hypothermia

This is the stage that happens when either we are kidnapped by the abominable snowman to be his snowbride and can't get away, or we are too irritable and argumentative to listen to our friends about going inside somewhere warm.

The core body temperature drops below 90 degrees Fahrenheit (32 degrees Celsius), yet is still above 82 degrees.

The signs and symptoms are as follows:

Violent shivering to No Shivering (the shivering is progressively inhibited until it stops)
Loss of muscle control
Loss of ability to make rational decisions

(I know what you're thinking: there are some people out there that are so irrational that they must be hypothermic in 120 degree weather. Those people don't count. They would already have been eaten by abominable snowman for irritating him.)

Staggering Gait
Profoundly altered mental status (Think a fifth of vodka and a billy club to the head)
Apathetic attitude
Urinate in Clothing
Paradoxical Undressing (You might get a strip show)
Finally, consciousness will be lost

The line between moderate and severe hypothermia gets blurred.

You know what, all this talk about cold and hypothermia made me want to make myself some hot chocolate... well, actually, hot vanilla, because I am allergic to the cocoa plant. Since I like my drinks robust, I got this hazelnut flavoring product just to add more calories.

After putting two tablespoons of it in my drink, I noticed on the side of the hazelnut powder a warning label that says: 'Warning: Don't store near open flame. May combust.' And I thought to myself: It may combust, but we can still eat it. How is that supposed to be healthy?

Then I suddenly remembered as I almost burnt my tongue on the hot vanilla that hot beverages can give you esophageal cancer. Yes, while studying for the board exams, I discovered that fact. So I added whip cream to it. Mmmmm, extra calories. But they're cold calories so they combat the esophageal cancer.

So here's to spontaneous combustion and esophageal cancer. Bottoms up. Mmm... hazelnut-chemical-induced-hot vanilla-water-that-has-been-nuked-in-a-microwave. Yummy!

Severe Hypothermia: Human Popsicle

Core temperature below 82 degrees fahrenheit. At this point, the heart is at risk of going into ventricular fibrillation.

Loss of Consciousness
Pupils fixed and dilated
Rigid and unresponsive
Can't feel their pulses
No respirations
Not yet dead

Here's a deal in prehospital medicine: The person is not dead until they are warm and dead. So here you have two EMTs debating whether or not the caveman trapped in a block of ice was still alive or not.

Treatment of Hypothermia: Handle with care

Let me put it this: manhandling a hypothermic patient is a very bad thing. You rustle them too much, you can cause them to have a heart attack.

1. Remove the patient from the cold and keep them laying down.

2. Remove wet and/or constrictive clothing. Constrictive clothing, especially boots, should be removed to reduce the risk of frostbite.

3. Wrap them in warm/insulating layers. Preferably two layers or more. (Protect the insulation from getting wet as well.) No water for you! [Note: Fabrics such as fleece, wool, or polyesters, actually retain their insulating capabilities, even when wet.]

Insulate from snow, ground, wind, etc. If it's cold, keep it out.

4. Add a vapor barrier to eliminate evaporation. Saran wrap. Just kidding, but a water barrier such as a space blanket would work.

5. A fire should be built with a reflective surface behind it to direct the heat at the victim. I'm thinking a mirror or a log with aluminum foil over it.

Keep in mind that a fire itself does not effectively rewarm a hypothermic patient. And whatever you do, don't put them to close to the fire. You're trying to rewarm them, not flambe them.

If Mild Hyperthermia:

6. Give the patient warm high-energy drinks like my hazelnut-combustible-hot-vanilla-nuked-water. No alcohol. Chicken noodle soup works as well.

(Warning: before you start shoving liquids and food down the patient, make sure they can swallow without choking.)

7. Use external heat sources. Preferably in their armpits and on their chest.

Don't rub their extremities! Rubbing them sends cold blood back to their heart and actually lowers their core body temperature.

Heat sources can include: hot water bottles, warming blankets, blow by heaters, and/or chemical or charcoal heat packs. Don't apply the heat sources directly to their skin, but over thin layer of cloth.

If Moderate-Severe Hypothermia: Think slow cooking.

Field warming can be a very slow process. Just check your turkey thermometer every hour... 24 hours or more may be needed in order to rewarm them.

8. All of the above. Except don't give an unconscious patient drinks.

Don't use hot water or a heating pad on them. Instead apply warm compresses to their neck, chest wall, armpits, and groin.

And cut off their wet/constrictive clothing to avoid moving them too much.

9. Add warm and humidified oxygen.

I know what you are thinking: You're out in the wild, where would you get an oxygen tank. So if one is not present, don't think that you have to sit there and blow in their face.

This is not a major means of warming the patient.

10. DO NOT immediately initiate chest compressions in a moderately-severely hypothermic patient with no pulse. First, do rescue breathing for three minutes, then take another sixty seconds to assess their pulse.

CPR should only be preformed if there are no signs of life present in the victim.

If you have anymore questions concerning hypothermia and its treatment, please feel free to email me.

Hypothermia: Jack Frost's idea of a Sick Joke, the Beastard

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sat, 23 Jan 2010 18:00:00 +0000

The start of 2010 brings with it streamers, noisemakers, happy people singing, and a busload of freaking-cold weather.

We look outside and see that pretty white stuff glistening in what could barely be deemed sunshine, and we think, 'wow, it would be so much fun just to roll around in that making angel figures because I want to freeze my butt off.'

See that's what the snow wants you to think. It's sending out subliminal messages: "Play in me, I'm soft and fluffy. You'll love it. Don't mind the frozen extremities; they'll grow back." It's evil, I tell you. Pure evil!

So, knowing this, you do what any sane person would do: You take the sled out with the kids and get completely iced over. At the same time, Jack Frost is waiting out there, stalking your noses like a polar bear does a herd of seals.

In a perfect world, we'd have built in heating pads. Okay in a perfect world, we'd all have killer bodies and own mansions. But we're not in a perfect world: we're in a world of chapped lips, runny noses, and frostbite. Yes, as you can see, I am a-cup-is-half-full-kind-of-girl. The chapped lips thing is making me bitter. ;)

I'm going to plug a very good book at this point, and the sad thing is that the authors aren't paying me a lick of doe for it. I know, I know, you're feeling great sympathy for my plight. Thank you, I appreciate every tear on my behalf. :)

In all seriousness, Hypothermia, Frostbite, and Other Cold Injuries: Prevention, Survival, Rescue, and Treatment by Gordon G. Giesbrecht, Ph.D. and James A. Wilkerson, M.D. (www.mountaineersbooks.org) is a very good book for this time of year, especially if you have children.

My brother has seven kids, which includes two sets of twins. Can you ever imagine wrangling two 2 years and two infant babies at the same time? He and his wife have got their hands full. One afternoon their eight year old girl came home crying of her feet being so cold they were numb. So as any knowing parent would, my brother said, "Well, if your toes fall off, you'll remember that I told you to come straight home and not to play out in the snow."

Let's talk about numb toes and red noses, or in other words, hypothermia: The cold's and water's evil love-child.

Just in case you were wondering: "Hypo" means under and "thermia" is Greek for heat or temperature. (I feel like that father on My Big Fat Greek Wedding; "Show me a word, any word and I will show you the Greek root of the word.")

Hypothermia occurs when the body's core temperature drops below 35 degrees Celsius or 95 degrees Fahrenheit. That's not a lot of leeway considering the normal human body temperature is around 37 degrees C (98.5 degrees F).

You see our bodies are stubborn: they hate change. Any change and they decide to shut down. It's like some sort of mutiny. "You wanna drop my temp a couple of degrees, huh? Well, I'll show you!" It's like a living Union.

Truth be told, in acclimated populations, the human physiology has incredible mechanisms that tolerate severe cold. For instance, the aboriginals of Australia can easily sleep on frozen ground without shivering. (See Giesbrecht and Wikerson's book) The women of Tiera del Fuego can breast feed during a blizzard without discomfort. Inuit men can easily work with their bare hands in sub-freezing temperatures for extended periods of time. Well, good for them. Let's give them a medal. As for the rest of us, we have a hard time adjusting to falling temperatures. Hence, we develop hypothermia

The worst part about it is that we are bull-headed enough that during the first stage of hypothermia that we deny the fact that we even are cold. Then we get irritable if anyone dares suggest that we bundle up or put on gloves. Yes, it's true. One good dose of hypothermia and we become like the Exorcist. Our heads start spinning, and we smack-talk to anyone trying to help us.

For instance, just the drop of 1 degree C in core temperature causes impaired judgment and slows our reaction time by half. If our temperature falls below 35 degrees C, then we lose the ability to make rational decisions. We become, well... like mean drunks. I can just see the TV ads now: "Friends don't let friends drive under the influence of hypothermia." Or the support groups: "My name is Joe and I am a hypothermic."

Temperature drops below 32 degrees and our only innate heating system of shivering stops. At that point, we are two steps away from laying down and becoming a human icicle.

Here's a question for all the parents out there: Who tends to get hypothermia worse, you or your kidlets? Unfortunately, the kidlets do. Actually, babies, children, and elderly are most at risk. But for the purposes of this post, we'll focus on children, since the elderly are more likely to stay indoors during this time of year. They don't seem to find the joy in freezing their butts off. Go figure.

Anyone remember the little brother on "A Christmas story" being bundled up to look like the Michelin man? Now that mother was smart, she knew about this kid-care fact. Forget about her child's social life, she prevented his hypothermia.

Okay, so maybe she went overboard. I mean really look at him, the boy looks like he can barely waddle. That's a sure ticket to getting your kid beat up. And then you'll have to deal with taking care of broken bones and bloody noses... but that is a totally different blog.

Now, we don't have to go to that much of an extreme. But we can take into consideration that the manifestations of hypothermia in children don't present in the same manner as in adults. Due to this fact, hypo- and hyperthermia are very common ailments in children.

All on their own, children are interesting little rug rats. Just like my brother's little girl, kids get so engrossed in playing that they tend to forget they even have bodies. Whereas an adult would say, "Heck with this, I'm cold. I'm going inside." A child would say, "What those are fingers turning into ice chunks? Who cares, just one more turn on the sled."

In addition to that, children lose heat more quickly than adults do, mostly through their head. And you wondered if they stored anything up there at all.

You know, I was studying the causes of hypothermia in children and one of the most common causes was alcohol ingestion.

Now, I just want to know: Who goes about giving alcohol to kids? "Hey, Billy, I know you are five, but I think it's high time that you start drinking if you want to fit into with the rest of Mickey's club house." What the heck?!

Granted, the ingestion of alcohol could be due to taking OTC cold medicines like Nyquil, but who in their right mind would send a kid with a head cold out and doped up on medicine into the snow?

(Just FYI, alcohol causes vasodilation of blood vessels, preventing the body's natural defense against hypothermia of shunting blood away from the extremities and skin.)

Anyway, I'll step off my soap box and get back to this post.

Other common reasons why children are more susceptible to getting hypothermia than adults:

*Children have smaller body masses, relative to their surface areas, leading to increased heat loss.

*Children have limited glycogen stores to support increased heat production in response to cold.

*Very young infants don't have the ability to increase body heat through shivering.

Also, once children develop hypothermia, they are less likely to turn into mean drunks like adults do, despite having more severe hypothermia.

The following is a list of things which you can do to prevent hypothermia when outdoors:

-Use a weatherproof outer layer. In sub-freezing temperatures, use a breathable nylon fabrics with an insulating layer of fiberfill like Lamilite.

-Avoid Cotton. Wool base layers are essential, and most importantly avoid wearing cotton under clothes.

-Don't over layer. When playing or working, people sweat. I know, I know: it's hard to believe, but the little sweat fairies wave their magic wands over your pits and boom! Beautiful, glistening, saline comes oozing out of your pores.

Now, what happens is that people get hot under too many layers while playing or working, so they sweat. Then, they unzip the layers and the sweat evaporates, cooling them down. They zip their layers back up. Yet, they still are damp underneath and thereby their core temperature drops even more, and pretty soon, they are hypothermics.

-Instead, layer when not active. When you are working or playing, wear only enough layers so that you're a little cold. When you sit down to rest, add on more layers. When you get back up to play, remove the extra layers.

-Items to Bring. Hat (extremely important). Gloves. Bandanna or hankerchief. Extra socks.

-Stay Dry. Don't get wet inside your clothes or outside your clothes.

-Eat high energy snacks. Snickers bars do come in handy. ;). Actually, eating things like granola and apples can help a lot.

Next time, the clinical manifestations of hypothermia will be discussed and how to treat it.

Here are the links of the day:

http://www.osteopathic.org/index.cfm?PageID=you_frostbite This link is for information on how to fight frostbite.

http://www.emergency.cdc.gov/disasters/winter/staysafe/hypothermia.asp

http://www.nia.nih.gov/HealthInformation/Publications/hypothermia.htm

http://www.outdoors.org/recreation/hiking/hiking-hypothermia.cfm

Incoming: Eminent Delivery, Part 1

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Fri, 22 Jan 2010 03:00:00 +0000

::::::WARNING: Due to the graphic nature of some of the images and videos of, there is some medical and anatomical details that may be not appropriate for children.:::::::::::

Then again, if you're a medical crazy person like me than you wouldn't mind your children learning this kind of stuff. (Image taken from www.babybumpdiaries.com)

Alright, here we go. Get out your full body armor, because we're about to take on blood bath.

Actually, the process of birth can be a quite beautiful thing. This is where women come as close to what it feels like bring life into this world. It's the great blessing from the Lord that allows us a chance to take part in creation. I say epidurals are great blessings too, but that's just me.

The first thing you must remember is to: STAY CALM and DON'T PANIC!

You may think it's funny, but I've seen grown men faint at the thought of their wives going into labor. You wouldn't beleive how many unconscious fathers that I have had to scrape up off the hospital floor.

The next thing to do is to get a birthing area set up. The area has to be level and flat, with lots of light and warmth. Believe it or not, but the baby, just after being born, is bare-butt-naked and wet. It's kind of like being a nudist in Florida and immediately being transported to the arctic circle for the little tikes.

Don on barrier gloves (preferably sterile), goggles, and gown.

Next take the chuk from your birthing kit, and place it under the mother's pelvis with the cotton-side up. remember cotton-side up.

When the mother looks at you like you're insane and yells, "What the heck are you doing?!" (Note: women in labor are less likely to censor their words.)

You can calmly say, "Don't worry, mam; I know what I'm doing: I read a blog."

Now as for the positioning of the mother, I have provided a video clip of a vaginal birth for you to have an idea of how things should be during the delivery.

Graphic Childbirth video

The following steps are to be considered during heavy labor:

1. Breathing. Yes you should breathe, but actually it is important to breathe. Have the mother take deep breaths, concentrating on her breathing when she is inbetween contractions.

2. Crowning. The baby's head appearing at the vaginal opening is known as crowning. At this point during contractions, instruct the mother to push, while two assistants push her bent knees back at her chest. (Having assistants push the mother's knees back towards her, opens up the mother's pelvis making delivery easier.) The mother should NOT push in between contractions.

Instruct the mother to take a deep breath and hold it for at least ten seconds while she pushes. The idea of pushing is similar to that of bearing down to go to the bathroom... I know the guys can relate to this one. They have their newspaper and spend hours bearing down.

Warning: because the mother is pushing, most times the baby is not all that is 'delivered', so don't be surprised if a bowel movement precedes the baby's delivery. Just place another chuk or towel over the feces and continue with the birth.

3. Assist the head. Place your hand against the area below the vaginal opening and gently apply pressure during each contraction.

I had an OB preceptor that liked to used his knuckle here and dig in hard, because he could get his knuckle under the baby's chin through the perineal tissue. But since emergent deliveries are natural (non-epidural) deliveries, I highly suggest that you gently place your palm there... that is, if you want to live.

4. Appearance of entire head. As the baby's head is being delivered, gently support it with your hands. The baby's head, in most deliveries will appear chin down, then as the body turns to reconstitute, so that the shoulders can deliver, the baby's head will then turn to the side.

As soon as the head is out, tell the mother to stop pushing. Because at this point, you need to clean out the baby's nose and mouth.

5. Cleaning out the mouth and nose. The bulb syringe in your kit is essential for this step. Suction out the baby's mouth then nose. Use a clean towel if no syringe is available. (Images and videos taken from: Bookside press)

6. Nuchal Cord. If the umbilical cord is wrapped around the baby's neck, DO NOT attempt to cut the cord. Instead, place a finger under the cord to slip it off over the head.

If the cord will not slip over the baby's head, keep a couple fingers bracing it from tightening further around the baby's neck during delivery.

Normally, OBs cut and clamp the cord, but it takes experience to be able to effectively perform it. So I would highly suggest avoiding cutting the cord at this point in the delivery.

7. Head is delivered. The rest of the body should deliver with ease. Some baby's are with such ease that they literally slip out, others have broader shoulders and take some work.

The upper shoulder should present first, help it along by guiding the baby's head downward while the mother pushes. Once the top shoulder has delivered, then help guide the baby's head up when the mother pushes. (And I seriously mean guide, not pull on.) Then the bottom shoulder will deliver and then all baby's pop out at this point. So be prepared to catch.

8. Baby is out. Wrap the baby in a clean, dry and preferably warm towel or blanket. The baby should cry. Then place the baby on the mother's stomach.

If the baby doesn't cry or isn't breathing, keep the baby at the level of the mother's vagina. Place the baby's head lower than its feet. Stimulate the baby by rubbing its back. If still not breathing, give two quick gentle puffs of air into the infant's nose and mouth.

(Further resuscitation measures, should be left for a different discussion.)

Once baby is crying and breathing, place baby on mother's stomach. Skin to skin is the best.

DO NOT pull on the umbilical cord.

9. Cutting the cord. There should be two plastic, sterile clamps in your OB kit, or two kelly clamps. If you don't have either available then tie a clean shoelace or thick string, firmly around the umbilical cord, no closer than 4 inches from the baby's navel. (DO NOT use thread: it will cut through the cord.)

Tie another shoelace or thick string a few inches away from the first tie towards the mother's side of the umbilical cord. Make sure that both ties are secure, then using a sterile pair of scissors or scalpel cut the cord in between the ties.

10. Placenta. The placenta normally delivers itself. Usually a gentle kneading on the mother's belly helps the process, but I am going to leave the details of delivering the placenta to the following video. As for after the placenta is delivered, place it in an airtight container to take to the hospital with the mother.

11. Clean up. Gently (and I mean GENTLY!!!) wipe the blood off the mother with gentle soap and water. (Baby shampoo is a very good form of soap for wounds.) Fill a thick, feminine napkin pad with a little ice and place over the vagina.

12. Get to the Hospital. If you cannot get to medical help at all, then keep both mom and baby dry and warm. Keep the mom hydrated and watch the both of them closely for signs of shock.

13. Now you can Relax. Well, either that or pass out, because you just delivered a baby.

Since there is so much material concerning emergency births, I was unable to cover it all. Please refer to the following sources for more information on emergent deliveries:

ParasolEMT.com

Babypartner

Planbaby.com

Healthopedia.com

AHealthyme.com

Delivering Babies: So Grizzled

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Wed, 06 Jan 2010 04:23:00 +0000

Delivering babies can be a grizzled job. How grizzled?

Let's just say that the field of Obstetrics (OB) is kind of a Wes Craven meets the Care Bears situation: Blood, guts, gore, and cute little baby butts.

So there's a very good reason why obstetricians prepare like nuclear fallout specialists to deliver a baby. They have to fend against an all-out military airstrike with the baby as the Drill Sergeant: "Alright you bodily substances, you better hit 'em with everything you've got! Darned, if they make me come out into the world! So bring on the rain!" Then hence starts the artillery.

During one of the last deliveries that I performed, the umbilical cord sought its revenge and sprayed my face like Old Faithful. It was not pretty; kind of like the aftermath of the movie Carrie. I think I heard the dad scream.

For instance, cesarean section yields enough blood to make a general surgeon cry, "oh mommy!", but then the OB doc pulls out a tiny baby buttocks out of the gaping abdominal wound and everyone in the room goes, "Ahhhhhh! Isn't that cute!"

Now, you are probably wondering, why I would bother to talk about baby butts in a disaster and wilderness medicine blog. But that's just the point, just like in the world of OB, anything can happen. And you just might find yourself needing to deliver a baby.

First, in this post I am going to discuss the things that you should have on hand in order to perform an emergent delivery. (Emergent delivery: if you are in a situation where in you can't contact 911 or are unable to get the laboring mother to a hospital in time.)

In the next post, I will describe how to perform an emergent delivery. This is not to replace the work of medical professionals, instead it is designed to help you handle an imminent situation where appropriate medical help can not be obtained. (Image obtained from www.lifemedicalsupplier.com.)

As for gear, many companies offer pre-made OB kits which you can purchase online, which I personally prefer, because I'm too lazy to make my own. Or you can purchase the products separately and build your own. Lazy way is better.

The following is a list of items that should be contained in any Ob kit:

*One pair or more of sterile exam gloves. These are the gloves that are generally worn by OB docs in order to perform sterile cervix exams. I suggest having more than one pair.

*One disposable plastic apron or surgical gown. I'd personally go with the surgical gown, more coverage. You know, from a disaster perspective, I would stock up on disposable surgical gowns, but that's just me and I am biased towards having more medical supplies.

*One 17" x 24" under pad. In the medical arena, we call these "chux pads". These are plastic on one side and cotton plush on the other. The closest thing out in grocery stores to them are puppy pads, but I wouldn't suggest using a puppy pad for delivering a baby.

*Disposable Absorbent Towels. I would stock up on these. They are good for any medical emergency dealing with body fluids.

*Biohazard bag. Again, good for any medical emergency where instruments can become contaminated with fluids.

*Plastic Drape sheet. Okay, I have to admit that lots of blood equals need for lots of plastic coverage, whether it be in the wilderness or in your home.

*One heavy duty feminine pad and Ice. I personally like the ones that you can either fill with ice or can open enough to shove ice in them. The ice helps alleviate the pain that occurs post-partum in the perineum. The pad itself absorbs the post-partum blood.

*At least Four Sterile 4 x 4" guaze sponges. Really, if you don't have these in your emergency medical kit already than you have a very poor quality kit.

*One Sterile Scalpel. Preferably a #10. (Image taken from www.canfsupply.com)

*One Sterile 2 oz bulb syringe. I think this should be in any emergency kit notwithstanding whether the kit is designed for baby delivery or not.

*Alcohol Prep pads. Okay, these are a must regardless.

*At least two Sterile Umbilical Cord Clamps. Or you can use Kelly Hemostats. (To sterilize the hemostats: Place hemostats in water that has been brought to rolling boil for at least 15 minutes. Note: water sterilization kills most bacteria and inactive viruses, but doesn't kill prions which are the cause of Bovine Spongiform Ecephalopathy [also known as Mad cow disease] or Creutzfeldt-Jakob disease. But most likely, you won't encounter Prions on clean medical equipment.) The sterile clamps are the cream colored plastic pieces seen in the picture.

If you are unable to obtain these things, or they are not on hand when an emergency birth takes place. Get out your boiling water, toss a sharp blade in and some shoelaces. Boil for 15 minutes.

In a later post, I will describe the different types of sterilization techniques.

Next time, we'll discuss how to perform an emergent delivery when birth is imminent and medical help is unavailable.

If you have any questions or comments, please feel free to email me at disaster_medicine@yahoo.com.

Until next post,

Christine

Pigs in Your Blanket: What to Do When H1N1 is in Your House

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Tue, 20 Oct 2009 19:46:00 +0000

Alert! The swine flu has marched its coughing army of viral genetics into your safe haven... it has blown its way into your home.

The porky enemy has infiltrated your territory. The siege is over and the swine have broken through your defenses. Your walls are breached and your pants are down. There are piglet particles everywhere.

Some of your team have been compromised, maybe even your second-in-command (your spouse). What do you do? Are you going to give up? Are you going to throw in the towel and run out screaming, 'the piggies are coming, the piggies are coming'? No! Heck, no!

You are one tough mommy! You don't fall weak at the sight of puke and pustules. You are supermom or superdad. Your motto is: 'Never give up! Never surrender!' Okay, so that's the motto from Galaxy Quest, but you borrowed it and tattooed it on your buttock.

So now that you have built up the resolve to take down the enemy swine, what do you do next? You do what any normal military person would do, you hedge off the areas that have been compromised, tend to the wounded, and do your best to keep from becoming a military casualty yourself.

At this point in the war on H1N1, you know that the time for bellyaching and fear-mongering is over. Now is the time for buckling down, rolling back your sleeves, and heading N95 mask first into the pig pen.

You remember all those old movies about the crusty old army sergeant that forges back into the line of fire to save a fallen comrade: well, that crusty old sergeant is you. This is your moment; you have trained for it and you are going to kick some swine flu butt. You stand in front of your sickly family and shout, "Are you with me?!"

Okay, so your family looks at you as if you are the village fruitcake. Maybe the two-year-old applauds, but they all return to their beds moaning and you are left to tackle the flu on your own.

Well, you're not entirely on your own; the CDC has established some steps to lessen the spread of flu in the home. They have offered you the almighty handbook of "Security Lock-Down 101."

Rule 1: Solitary confinement. The CDC suggests keeping the sick person away from the other members of the household as much as possible, especially those that are high risk for complications from the novel H1N1.

I have to say here, how in the heck is that supposed to work if you have children sharing a room and the only other room in your house is the only last safe haven you have from children, or at least it is until 3 am when your toddler comes jumping into bed with you because the boogie man set up shop in their closet.

But anyway, the CDC suggests that you keep the sick person or persons in a room separate from the common areas of the house. ("For example, a spare bedroom with its own bathroom.") And keep the designated sick room shut at all times.

Oh yeah, a three year old child is going to love the solitary confinement while they feel like crap. How many three-year-olds do you know of that enjoy being absolutely alone when they need comfort from mommy or daddy? And I doubt the six-year-old sick child is going to stay put.

The curious thing about children is that they can and will play up until they are so sick that they can hardly stand. At that time, they begin to shows signs of lethargy and confusion. At that time, they should be visiting ye ol' emergency room, sporting a face mask. While we adults, the first moment we feel ill, we're done playing. (I'll talk about this phenomena more in my posts on hypo- and hyperthermia.)

Rule 2: Careful Transport of the Compromised. The CDC suggests that if the sick person does have to walk through they should wear a mask.

Rule 3: Hedge off the Enemy, Don't Allow it to Compromise Other Bases. Try to keep visitors to a bare minimum. Children when sick can transmit the virus up to two weeks after the last symptoms have gone. So if their friends come over to visit, there is a high likelihood that they can catch the disease and bring it home to their own families. And I'm sorry, misery shouldn't like company.

Rule 4: Keep Yourself From Becoming a Military Casualty. When holding your sick child to comfort them, hold them so that their chin is over your shoulder and turn your head away when they cough. If you come down sick then who cares for your loved ones.

Also, if possible try to wear protective gear to prevent the spread of infection. When leaving the patient's room, remove the protective gear to a designated location and wash your hands.

Rule 5: Clean the Barracks. Laundry should be washed with hot water and bleach if possible. Don't hug laundry to yourself when placing it in the washing machine. Use a laundry basket and gloves. After handling laundry, wash your hands and wipe the area with disinfectant.

In the kitchen, designate a specific set of dishes and utensils for your sick loved one to use. And wash those dishes in hot water in a dishwasher, if possible. Try to keep those dishes separate from the rest of your family's dishes.

Wipe down surfaces, bathrooms, door knobs, etc. with disinfectant sprays constantly.

Rule 6: Call in for Backup When the Enemy Becomes to Powerful. I have listed a series of signs in past blogs of when to go to the ER. Keep in mind that the H1N1 comes on fast. It doesn't wait for a few days to gather its strength, it hits you like a ton of bricks on the fastlane.

A lot of primary care providers are concerned, because of the possibility that patients can come into their offices with seemingly harmless symptoms and within less than 24 hours are in deep distress with full-blown H1N1.

On a single day, a particular hospital reported that there were 50 admissions for H1N1 with 19 of them being transferred to intensive care. The majority of these cases appeared at first looking like they had the common cold.

Recognize when to cut your losses and go to seek professional assistance.

Rule 7: Like all Things, This too Shall Pass. The truth is that I have seen many cases of H1N1 in this last week, where the family has recovered together. Careful planning and attention to warning signs will help you and your family stay safe this flu season.

On a serious note, please keep hydrated. Please get enough rest and vitamins. And for the love of Miss Piggy, please seek medical attention when you start feeling an illness come on quickly.

If you have any more questions concerning H1N1, please utilize the comments section of this blog. I will try to reply to your questions as soon as possible.

Three Little Swine Flu Pigs: Huff and Puff and Cough Your House Down

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Sun, 18 Oct 2009 00:05:00 +0000

There's something to be said about humor in medicine. Some say it's the spice of life. I say it is the anti-nausea drug of the healthcare profession.

Seeing gross things all day, leaves you with two options: You either blow chunks or you laugh... then again, technically you can do both, but I wouldn't advise it.

For instance, when you see the montauk monster of all diseased masses sitting on top of a beating heart, you can easily find yourself heading for the horror flick, "Breakfast Strikes Back." Yet, one good twisted sonnet from the anesthesiologist about his love for the Beatles and your stomach settles.

Then again, it's not like physicians spend all day long laughing at everything to keep themselves upchuck-free. Seriousness has its place. In fact, you can always tell the danger of the case by the amount of humor that passes between the surgeons and hospitalists. If they are singing songs about the names of the new residents, then they are prepared for the case. If they are silent, its bad news and something unexpected of which they weren't completely prepared for, has happened.

The point of these blogs is to utilize humor in preparing now for the serious disasters that can occur later. And there is nothing more serious than witnessing one of your family members suffer from a life-threatening illness. When a loved one starts to suffer, the first response should be to roll back one's sleeves and to take care of them. It shouldn't be 'to panic.'

True, you do have to have the stomach for the work. Not very many people can cleanup puke without dry-heaving. You should have seen how fast my brother's house cleared out of people when his toddler vomited on the couch. Everyone screamed and ran like she was one of the undead coming to feast on their brains. All that remained of her siblings were dust clouds.

Yet, even if you are a little queasy in the face of blood, guts, and gore, if you know beforehand what to do, then you'll quickly adapt.

The ability to laugh during a time of crises is a sign of a well-prepared person. The preparedness I am talking about is not just collecting the temporal materials necessary to survive, but more, the knowledge and training that would keep you from panicking. So, in my blogs, I intend to do my best to help you become mentally ready to face the trials that lie ahead... or at least, the disaster and medicine-related ones.

In this post, I am going to start with the CDC recommendations for taking care of a sick person and in the following blogs, we'll elaborate more. Then that will conclude the H1N1 series and we'll start working on wound care in the wilderness and what to do in the event of an earthquake. (That's my favorite stuff!)

Now, let's roll back our sleeves and get cracking on what to do if someone in your house has contracted the virus. (The following words of advice are derived from the CDC standard of home care in the event that someone has contracted the novel H1N1: http://www.cdc.gov/H1N1flu/guidance_homecare.htm)

First and foremost, if you have children or teenagers, DO NOT give them aspirin (acetylsalicylic acid). Doing so could cause them to acquire Reyes' syndrome. It is an incurable and potentially fatal syndrome that affects all organs, especially the brain and the liver, resulting in severe encephalopathy (swelling of the brain) and a fatty liver. ( For more information on Reye's syndrome: http://www.ninds.nih.gov/disorders/reyes_syndrome/reyes_syndrome.htm)

The over the counter drugs that the CDC recommends are Ibuprofen (Motrin, Advil, Nuprin, PMS-bane, etc.), Acetominophen (Tylenol), and Naproxen (Aleve). You can give children's tylenol to a baby 6 months old or younger (please contact your provider for details) and both ibuprofen and tylenol to children 6 months of age or older. (See also, the American Academy of Pediatrics parenting corner at http://www.aap.org/publiced/BR_Infections.htm)

I do have to mention here that we live in a more is better society. More makeup will hide that zit. More sugar will fix the bad taste of my spouse's cooking. More cartoons will keep my kids from tearing up the house. If it works a little, then more is better, right? Wrong.

Well, let's just put it this way: the only time "more" is better in medicine is when you apply more love to taking care of your patients, and even then, there are times when more is definitely not better. So, please for the sake of all that is good and holy, don't apply the 'more is better' analogy to the above mentioned drugs. Please, just follow your health care provider's advice on dosing or you might end up doing more damage than good. (Image taken from http://www.drugbuyers.com/freeboard/ubbthreads.php/topics/907257/Re_Funny_gifs_post_them_here). For instance, a painful death can result from taking more Tylenol than the maximum dose allowed. [The maximum dose of Tylenol in an adult that is allowed is: 1g/dose(1000mg per dose), and 4g/24h (4000mg per day)].

If you drink more than three alcoholic beverages per day, then one, you really should talk to your doctor before taking it, and two, never use more than 2g (2000mg) per day. Avoid Tylenol, if you have liver disease.

In addition to that, the American Academy of Pediatrics strongly recommends that parents should avoid giving any over the counter cough and cold medications to infants and children under the age of 2 years old, due to the risk of harmful and life threatening side effects. Also, many studies have shown that cold and cough products are not as effective in children younger than 6 years old. (Please see: Common Childhood infections, American Academy of Pediatrics, 2005, updated April 2008.)

So in a nutshell, please seek advice from your primary care physician before taking any pharmaceutical agents, for dosage instructions and any possible contraindications that you or your loved ones may have. (For more information on the side effects of these drugs, refer to: the Food and Drug Administration: http://www.fda.gov/ForConsumers/ConsumerUpdates/default.htm. And also, http://www.tylenol.com/page.jhtml?id=tylenol/children/subchild.inc, and https://online.epocrates.com/u/10a307/acetaminophen)

As for when to seek emergency care, I mentioned in an earlier post about what signs to look for. If the person you are taking care of, or you yourself have any of the following, then please seek medical help immediately:

*Has breathing difficulties

*Has chest pain

*Is vomiting (unable to keep liquids down)

*Has seizures (uncontrolled convulsions)

*Has purple or blue discoloration of the lips

*Acts less responsive than normal or becomes confused

*Shows any signs of dehydration, such as decreased or absence of urination, sunken eyes, dry mucus membranes (inside of mouth is dry), lack of tears when crying (in infants), or dizziness upon standing.

* Has a high output of diarrhea (That is if diarrhea is present. The CDC has indicated that some patients may experience diarrhea from the H1N1.)

In taking care of a sick person, it is important to keep them properly hydrated: 8 to 10 glasses of water a day. More, if they have vomiting and/or diarrhea.

Oral rehydration should be given to the patient in small amounts frequently, such as in small bottles for infants "paced to mimic sipping," and in spoonfuls or small sips for toddlers. (Except avoid giving water to infants under 6 months old, instead refer to your pediatrician for rehydration instructions.)

The WHO suggests replenishing fluids in cases of diarrhea and/or vomiting with rehydration solutions such as Pedialyte (Abbot Laboratories) or Gastrolyte (Aventis Pharmaceuticals). Or you could always go the cheaper route and water-down Gatorade (One part water, One part gatorade).

There is also the WHO solution for developing countries: One liter of pure water, two tablespoons of sugar, and one-half tablespoon of salt. I say add some lemon juice to it. Or you can always switch out the sugar for honey, except in cases of infants under the age of one. The American Academy of Pediatrics has strongly advised that children younger than 1 year of age should not be given honey because of the possibility of food contamination.

Another alternative remedy, you can try is the Apple cider vinegar mix:Two tablespoons of cidar vinegar (not the clear or distilled kind) and one tablespoon of honey combined in one cup of water each morning.

My favorite is mixing one tablespoon of honey, the juice of one lemon, a pinch of salt, a pinch of ginger, and a pinch of cinnamon in one cup of warm water. The mix should be done to taste. If the sick person can't handle the strength of regular ginger, than instead, use gingerale in place of ginger and water.

In the next post, we will discuss what measures should be taken to lessen the spread of flu in the home. Good luck until next time.

So, Ta Ta for now; I have echocardiograms to study.

Board Exams are Evil Spawned by Satan

noreply@blogger.com (Dr. Christine Princeton, D.O.) — Fri, 16 Oct 2009 02:49:00 +0000

If the title of this post doesn't warn you that I'm pausing in the H1N1 series to vent, then could I remind you of that ocean front property in Ohio that I'm selling? :).

Seriously though, earlier today, if you didn't catch it, I posted a list of natural agents that have antiviral properties... so I haven't neglected my blogging duties.

Anyway, I just want to say that the National Board of Medical Examiners are evil! First, they develop these 8 hour exams which we spend months studying for, gaining weight, and eating whatever is close enough to our grasp that doesn't have mold on it, while we become greater zombies with hackers' tans because we haven't seen the light of day for months! And all the time, we are sacrificing our social lives for the will of the Board examiners. (Image taken from www.matt-willard.com)

Okay, that's not true, I do have a social life: I have a very exquisite relationship with Harrison's Internal Medicine book, which I often find myself cheating on by sneaking off with Crush the Step 2. Then to mix it up, I spent a few nights every so often with First Aid for the USMLE and USMLEworld. Believe me, we became very intimate during the last few months. I took them out, we had dinner together. Of course, I paid; it is the 21st century. We slept together: but often I found myself, sneaking off early in the morning pulling a coyote ugly to get to the next board exam review book. I admit that I wasn't very committed to just one.

Then as with any deep relationship, it had to end the day before the exam. I think I found a Dear John note on my pillow, stating, "I can't take the neglect anymore. Signed Harrison's." Therefore, I went cold turkey. No more board review books. My Exam analysts were saying that it was for my own good that I was to part with them for a few days. Believe me, it was hard. I could hear to books calling to me, saying sweet nothings and begging me to take them back. It took all I had to walk away and say no more.

So there I was exam day, getting frisked for possible study materials that I might have sneaked in over the Prometrics center border. It was seriously like Fort Knox. They take your finger prints, your picture, your driver's license, your certificate of exam eligibility, your first born child... it was dreadful. Forget about the fact that you're already nervous from having to take the daunting test that could determine your future, but you also get shaken down like a drug dealer during a meth bust. "Up against the wall. Okay, frisk 'em. If we find any cheat notes, you're going downtown buddy."

So after the airport security picked my pockets, I found myself sitting in front of the ugliest computer screen I had ever seen in my life. The darned PC looked like it was going to croak right in front of me. I was half ready to yell out: "Quick! Call a code and get an AED!"

It makes you think, "All that action and all I get is this is fossil?" Which it only added to my stress because the whole time, I kept thinking that the piece of computer would crash and they would make me take the test over.

Eight hours. Can you believe that they make you take a test for eight hours? Well, at least there were breaks, but still, it starts to wear on you. During the seventh stretch of the exam, I felt like I was ready to throw in the towel. The darned thing had sucked out my brain and was now spitting it back at me in defiance. I couldn't take it. I just wanted the torture to end.

So I looked at the clock running down. Fortunately, I had time to spare. Thank heaven to all those English lit classes that I took just to get out of taking math. I couldn't ask for better lessons on how to read as fast as lightning than trying to get through the evil book of Frankenstein.

So I had two and a half hours left on the clock and only one more block of test questions. So I did what any knowing, burnt out medical student would do. I went bowling. Yep, I signed out of the test in a designated break place, went through security, and went bowling. After a full game of throwing a huge marble ball at some pins to blow off some test anxiety, I came back through the top secret clearance squad and finished the test.

Yeah, but was that it? Oh heck no! I'm a D.O. We osteopaths are gluttons for punishment. I had to take the COMLEX a week later. The COMLEX, for those of you that don't know, is the osteopathic version of the board licensing exam. It's eviler than the USMLE... those twisted National Board of Osteopathic Examiner beastards! And another 400 question test brought me back to the same testing center, through the same frisking process, and back to the same archaic computer.

So here I am now, sweating it a month later, and still my test results for the COMLEX are not back yet. I mean really, how hard is it to grade a test that was taken on a computer?

There must be some logical explanation for them to take so long to report back, because making someone wait several weeks for test results that could determine their future is too cruel and too absurd to be without some severe cause. So, I've been considering a couple of possibilities as to why the NBOME are taking forever to post scores: not even Al-Qaeda would be so intentionally inhumane.

So the following are ten possible reasons as to why they would take so long on such a seemingly easy task:

1. The satanic computer, mad at me for saying a prayer that it would survive the exam, ate my test. Evil, evil computer!

2. An Dark Evil Overlord has infiltrated the NBOME, plotting to take over the world by turning young doctors into mindless zombies that spend their whole day checking online for their test results.

3. Terrorists have abducted the NBOME Chief of Score Reporting, holding him ransom for a pound of pickles.

4. It's the end of the world and they know it. They feel fine... Yeah, they feel fine about not giving us our test scores. Punks! Well, I don't feel fine: I'd still like to see my score... A passing score would put a positive spin on the world ending.

5. The NBOME is an alien organization mothership from the planet Zerthon bent on sucking the hope and life out of the earth's young physicians.

6. It's a government conspiracy to keep us from finding out our scores. I think the alien one is more convincing.

7. An evil artificial intelligence infiltrated the NBOME's computer files, deleting all our test scores to make us humans suffer.

8. Barney the Dinosaur broke in and beat up the NBOME staff so that they wouldn't be able to post our scores. I knew that dinosaur was evil!

9. The NBOME are a cult dedicated to sacrificing our test scores to their unholy gods.

10. A dorky space ranger from the future came back and shot all the NBOME staff with a freeze ray to keep them from posting our scores which would send about a chain of events that may destroy the universe as we know it! I hate that space ranger; I'd rather have my test scores.

See, maybe there are very good reasons for them torturing us poor, unlucky test-takers. At any rate, I feel better now that I vented. :)

Post to you next time.

Christine

P.S. I figured out the NBOME motto:

"It's not that we don't care; it's that we don't want to care."