Now, there are as many different concerns regarding health as there are people.  But, throughout that vast sea of diversity, there are a lot of similar complaints that we share.  We are, of course, only human.  I have made my list of medicines after observing several very common, and very uncomfortable, complaints shared by many patients and family members alike (including even myself, from time to time, unfortunately).  I have grouped the list around major symptomatic themes, such as aches and pain, fever, stomach upset (either going too much or not enough), and simple infections.

Of course, as with everything medical, it is best to run medication choices by your primary care provider (PCP).  Based on your own medical history, medication allergies, and what medicines you are taking currently, your PCP will decide the safety and efficacy of the suggestions below.  For example, if you are the blood-thinning medicine Plavix (clopidogrel) for heart attack or stroke prevention, or if you have a history of recurrent gastrointestinal bleeding, then you should avoid taking aspirin, as it can thin your blood even further, and increase your risk of bleeding—perhaps uncontrollably.

One other state of health should have you in constant contact with a medical professional also—pregnancy.  I do not presume to know what medications you might be on while you are pregnant, but every one of the medications listed below should be discussed with your healthcare provider before taking it.  Most of these medicines are taken by mouth and enter the bloodstream, affecting the developing baby as well as you.  So, please, if you are pregnant, evaluate this list and consider the risks and benefits.  But please also talk with your PCP about your situation, and whether or not it is safe for you to be on some of these medicines.

A word of caution as well: this list does not include prescription drugs.  These medicines are presumably prescribed for a reason—to treat or manage a particular diagnosis (for example, a blood pressure medicine like metoprolol for treating high blood pressure).  You are supposed to be on these medicines already, and they should occupy an important space in your medication cabinet.  Going back to the pantry analogy, prescription medicines are like that must-have ingredient your grandmother insists you keep on-hand for that special family dinner (i.e., kale in a special soup).  It is essential for your recipe and cooking style, but not necessary for the next person’s pantry down the hall (he has a weird allergy to kale).

A special category of prescription medicines are ones that need to be refrigerated.  These are usually injectable, like insulin and medicines for diseases like rheumatoid arthritis or multiple sclerosis.  Please make sure that you have an adequate supply available, that your prescription is not going to run out soon, and, if it is, that you call your provider’s office at least two to three weeks in advance.  These medicines are very important to your health and well-being, and you should never be without them, or the appropriate supplies to administer them, like syringes, batteries for medical equipment like an insulin pump or glucometer (to test your blood sugar), and test strips.  Stock up on these supplementary supplies, follow your prescription and fill it religiously.  Know when it is time to get your refill, and when you need to have another script.  It is your health, and you need to be responsible for it, too.

Finally, this list does not include emergency medications, like an epi-pen for allergic reactions, or rescue inhalers for asthma.  You need them to live.  Keep them in your medicine cabinet, and check the expiration date regularly.  My father thought that he “outgrew” his allergy to bee stings… until he got stung.  Luckily, he still did have one epi-pen around and was able to prevent disaster.

Now, without further ado, here are eight medicines to have on hand that I feel are worthy of your consideration:

1. Aspirin:  A great, time-tested medicine that should be present in some form in your house (with a few notable exceptions, which I will explain below).  Aspirin, or acetylsalicylic acid, has proven very effective in reducing the risk of heart attack and stroke in millions of patients.  This medicine works by inhibiting the function of platelets—components of the blood that help us clot and form scabs.  Unfortunately, this process can also happen inside blood vessels, and if that clot completely blocks off blood flow, then, depending on where it is (the heart or the brain), the tissue cannot get nutrients and oxygen to live, and dies.

The most important reason to have aspirin in your medicine cabinet is that, if you think that you are having a heart attack and have called 911, then the operator might tell you to take aspirin tablets (325mg, or four baby (81mg) tablets), and chew them.  That’s right—chew them.  Studies have shown that the chemical gets into the bloodstream quicker if you chew the tablets than if you swallow the pills and let them dissolve in the stomach.  But, aspirin is a powerful medicine, and I do not think that anyone should start taking it without the direction and supervision of their primary care provider.  I say this for a couple of reasons.

First of all, aspirin can interact with a lot of other medicines.  As I mentioned before, aspirin and Plavix are both medicines that thin the blood, and taking both medicines can cause someone to bleed excessively.  Aspirin is also filtered out of the body by the kidneys, so any medicines that are also filtered by the kidneys (such as ibuprofen and other non-steroidal anti-inflammatories, or NSAIDs), can make the kidneys work very hard, and can actually damage them, potentially causing kidney failure.

Besides its interactions with other medicines, aspirin should also be used very cautiously with certain medical conditions.  These are mainly chronic diseases that predispose someone to bleeding a lot.  Some examples are stomach ulcers and other gastrointestinal bleeding problems, like a colon polyp, or clotting disorders like hemophilia (a rare genetic disorder).  It may still be safe to take aspirin, if you also suffer from heart disease or are at risk for a stroke, but you need to be monitored routinely by a medical professional and checked regularly for any signs or symptoms of bleeding.  People with kidney disease should also use aspirin under a doctor’s supervision, as it can worsen kidney function in high doses.

Another VERY important point about aspirin is not to give it to children to treat fevers (except in very rare circumstances, and only approved and followed, and probably even given, by a doctor).  This is because of a rare, but very serious, association between viral infections and aspirin use known as Reye’s syndrome, a condition which causes liver failure and brain damage.  It is VERY serious – potentially fatal – so don’t do it!  There are also people who have a known allergy to aspirin, and they also should absolutely avoid the medicine.  In fact, they should have a medical-alert bracelet stating that information, in the event of an emergency.  So, while aspirin has the power to potentially save your life in the case of an emergency, it can also be very dangerous and must be used and monitored with the care and cooperation of a trained professional.

2. Acetaminophen:  The active ingredient in Tylenol, this is another old, but very effective medicine.  Interestingly, Tylenol works on the same proteins as aspirin, but does so mainly in the central nervous system (which is the brain and spinal cord).  Both of these medicines are known as anti-inflammatories—they work to reduce pain, warmth, and chemical changes that are produced in response to an injury or illness.  Tylenol is very effective at quieting pain signals as well as reducing fevers.  But since it works in the brain, it doesn’t have the anti-clotting properties.  Because of this fact, Tylenol is considered safe in treating pain and fevers in patients who cannot take aspirin (as listed previously).

But like any medicine, there are important and potentially dangerous side effects that you need to know about to avoid.  The main ones with acetaminophen arise from the fact that it is filtered out of the body by the liver.  There is a set amount that the liver can filter daily.  If it gets more than it can handle, toxic by-products of the degradation process can build up and poison the liver, causing it to fail, and making someone very sick, or even be fatal.  Therefore, people who have liver disease (like cirrhosis) or hepatitis C (a chronic viral liver infection), really should try to avoid acetaminophen.  For healthy individuals, research has shown that the upper safe limit for daily acetaminophen use (which you should try to be well below, if possible) is about four grams.  If you are taking a 650mg tablet of Tylenol, that means your daily maximum limit is six (650mg x 6 tablets = 3900mg).  Of course, a lot of other medicines can have acetaminophen also, especially doctor-prescribed pain medicines (like Lortab, Percocet, and Vicodin, for example).  So, if you are taking these medicines, and Tylenol as well, you need to sit down with your healthcare provider and figure out what your daily maximum dose is, in order to be safe.

3. Ibuprofen:  Ibuprofen is very effective at treating a majority of everyday aches and pains.  It is the active ingredient in many arthritis and pain relief medicines, like Advil and Aleve, for example.  As with aspirin and Tylenol, it is an anti-inflammatory medication, a member of the NSAID family.  It works by a mechanism very similar to aspirin, but again has less (but not completely absent) effect on platelets and bleeding.  But it is a very potent anti-inflammatory drug, which makes it ideal for treating many of the muscle strains and sprains that we all suffer around the farm (we all know how I should have lifted that hay bale, but that twinge in my back lets me know that I used the wrong technique again).

The main concerns for ibuprofen are very similar to aspirin, namely bleeding and kidney problems.  However, there is one big contraindication for ibuprofen (and other NSAIDs, like Motrin and Celebrex)—and that is a history of heart disease or stroke.  Research has shown that people who take NSAIDs are at greater risk for having a heart attack or stroke.  So I would talk to a medical professional about your health problems and current medicines before taking ibuprofen.  But once it is approved, and if you use it sparingly (no more than two or three days in a row—if the pain has not improved by then, it’s time to go see a doctor), ibuprofen can be a very powerful ally in treating those occasional muscle aches and joint pains.

4. Muscle rub ointments:  Along the same lines as aspirin, acetaminophen and ibuprofen, external analgesic salves and ointments (translation: pain meds that are absorbed through the skin) can help relieve muscle aches and pains, and are very useful to have on-hand.  Most of these formulations, including common trade names like Bengay, have a compound in the same family as aspirin: methyl salicylate, also known as oil of wintergreen.  Some others, like capsaicin cream, have compounds derived from hot peppers that over-stimulate and inactivate pain receptors.  Both are very good medications for relief of localized pain like that found in arthritis or backaches.

The major benefit of taking medicated compounds in an ointment, compared to by mouth, is that the ointment works right where it is placed.  When you take a medicine like aspirin, however, it goes throughout your body, and interacts with nearly all of your tissues.  Besides keeping the therapeutic action right where you need it, external analgesics also help reduce the chances of medication side effects and drug interactions.  So with methyl salicylate, for example, you don’t need to worry about bleeding disorders or kidney problems, like you do with aspirin.  However, people who are allergic to aspirin, or peppers, should still be very careful when using these ointments, since they could also react to these ointments as well.  It is also important to use common sense, and not to ingest these medicines by mouth.  They are toxic when taken internally!  So please use common sense, and use them as effective local pain relief as directed.

5. Triple antibiotic ointment:  Another great weapon in the medicine arsenal is a topical antibiotic. (I know, I just went from the pantry metaphor to the war metaphor.  But with antibiotics, it’s convention I think.)  These are medicines that help reduce the risk of serious secondary infection, especially for those minor cuts and scrapes we all suffer on the homestead.  Antibiotics help slow bacterial growth, but do not cure the infection alone.  That is left to the body’s natural defenses (antibodies, white blood cells, and the like).

Topical antibiotics, therefore, allow people to safely and judiciously apply a potent and powerful medicine in a relatively safe manner in order to prevent a more dangerous infection or illness, and allow our body to help heal itself a little bit faster.  But as with all medicines, and especially for antibiotics, it is important to know what you are using, and how to use it.  The application is very straightforward—clean wound under running water to get rid of dirt, grime, and other yuckiness that might harbor pathogens, then take tube, squeeze ointment on cut, place bandage over medicine, and proceed with daily chores, repeating daily until cut is scabbed over or healed.  The medicines themselves, however, are a little more complex.

Most triple antibiotic ointments have three medicines: polymyxin B, neomycin, and bacitracin.  Huh?  Okay, so all of these medicines are pretty strong antibiotics that attack bacteria in different ways.  They work in a combined fashion on the bacterial cell wall and internal cellular proteins.  The important things to know is that these are very strong antibiotics, and are very poisonous if ingested.  So don’t eat them!  People who have allergic reactions to medications that contain sulfa compounds should also avoid using this medication.  Finally, after using the medicine, you still need to monitor the wound closely.  You need to call your doctor if the cut continues to look infected after several days (signs include redness, pus, or increased leakage of fluid from wound), or immediately if you have a new onset of fever, chills, weakness or dizziness with a worsening wound.  At that point, you might have a serious body-wide infection that requires intravenous antibiotics and hospital care.

6. Hydrogen peroxide:  I just want to say a brief word about hydrogen peroxide, since most of us know what it is and what it’s used for.  It is a compound that is unstable and readily forms oxygen free radicals—compounds that are poisonous to cells.  And that is ALL cells—yours, mine, bacteria, fungi, everything.  So it is nonselective in how it works.  My family likes to use it on our calves after we cut off their horns, to help prevent infection.  The secret with hydrogen peroxide is to use it immediately after the cut or injury happens.  You want to kill any potential bugs or threats from entering the wound, but then you need to give your own cells time to grow and divide, and heal the wound.  If you keep using it, though, it will kill those cells that are trying to heal the cut.  So, when I use hydrogen peroxide, I like to use it in combination with a triple antibiotic ointment.  I use it first to clean out the cut, then I apply the antibiotic to act as a barrier, with a bandage covering it all.  And, as always, use common sense—please do not drink hydrogen peroxide (it hurts the lining of your digestive tract).  People do brush their teeth with it, but just remember to spit it out.

7. Stool softener:  Now I would like to transition to some medicines, that, at first glance, might not seem as fancy as the pain relievers or antibiotics above.  But what they might lack in style, they more than make up for in substance, helping many people through some difficult situations.  The first, and most useful, are stool softeners. These include medicines like docusate and senna, and come with brand names like Colace and Dulcolax.  Many hospitals include them on their admission check lists, in order to save the patient (and frankly, a lot of the hospital staff) difficulties later on down the line.  All of these substances are types of fiber, and work by drawing water into the small intestine and colon, in order to lubricate and soften the stool and help keep the bowels moving.

There are not a lot of side effects with these medicines, and not many people have reported allergies to them (since they are inert fiber, and are passed out of the body anyways).  One main concern with these medicines is the possibility of worsening small bowel distention, or bloating, if someone has been constipated for a while, and the stool is starting to act like a plug.  The usual recommendation for stool softeners is to use them for two to three days as a trial.  If you are able to move your bowels while taking the medicine and relieve the constipation, then the trial is successful and you can go on enjoying life.  If there is no movement in the two or three days, however, then you might have constipation that requires an enema (using water or soapy water, mineral oil, or another marketed product, under some moderate pressure to the area), to try and relieve the blockage.  But for mild symptoms of constipation, stool softeners can be very effective, and save a lot of time, money, and discomfort.

8. Pepto-Bismol:  Then there is the other side of the equation.  We have all had those nights, when we’ve had one too many slices of pizza (or the entire thing, unfortunately), and your stomach is churning and rumbling.  I like having some bismuth subsalicylate (the active ingredient in Pepto-Bismol and similar digestive aids) handy, in order to calm things down.  It works by helping to slow the increased muscle activity of the stomach, as well as reducing irritation in the stomach lining by coating it, and acting as a mild anti-inflammatory.  The subsalicylate in the compound is actually a weaker formulation of acetylsalicylic acid (also known as aspirin, described above).

The main side effect of Pepto-Bismol is constipation, if taken in excess.  It should be avoided in children who are dehydrated, since this increases the chance of causing constipation.  It should also be avoided in children and teenagers who are suffering, or recovering, from a fever or known viral illness, because, as discussed above, there is the potential danger of developing Reye’s disease.  But I know that there are a lot of people out there (myself included), who have used and benefited greatly from using Pepto-Bismol or something similar, in order to enjoy a good night’s rest.

Well, there they are.  My eight must-have medicines.  I realize, however, as I said earlier, that there is going to be a lot of discussion and variation out there, and I think that is a good thing.  I had a lot of trouble paring down the list to these eight, since I did want to add a couple more, like antacids, and antihistamines like Benadryl, especially as an ointment (wonderful stuff!).  In fact, now that I think about it, there might be a couple of additions in potential future writings.  But, for right now, this is a good starting point.  I feel it is an important foundation for any homestead medicine cabinet, and will help treat a wide variety of mild to moderate medical conditions that we run in to on the farm.  By knowing how these medications work, how powerful some of them are, and when to stop taking them and consult a medical professional, we gain an understanding and respect that serves us well and helps us live more healthily and independently.

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Lyme disease is one of those hidden dangers.  And while a lot of information has recently been presented in the news, I have seen some misconceptions and erroneous facts presented.  So I would like to set forth a more detailed and concise description of the signs, symptoms, treatment, and prevention of Lyme disease.  I hope that this article will serve as an educational tool, helping to keep you safe as you continue to enjoy rural life.

But before we begin, here is the usual disclaimer.  This is for educational purposes only.  The information in this article is not intended for self-diagnosis or treatment.  If you feel that you are suffering from any of these symptoms, you need to be seen by a healthcare professional for proper medications and follow-up.  As will be discussed below, Lyme disease is a serious infectious disease, and it can have a lot of long-lasting health effects if not treated promptly.

Now let’s get to the matter at hand.  Lyme disease is an infectious disease caused by the bacterium Borrelia burgdorferi.  The illness derived its name from the town of Lyme, Connecticut, where the first cluster of cases were discovered and described in the 1970s.  It is carried in the wild by animal vectors, such as deer, mice, and squirrels.  The major source of transmission from wild animals to humans and pets is ticks.  In the northeastern United States, the hard deer tick (Ixodes) is the main species responsible for infection.  The infected tick, carrying the bacteria in its salivary glands, bites the victim and, during the course of its blood meal, regurgitates some of the bacteria into the wound and infects the victim.  The Borrelia bacteria cannot be transmitted from person to person by casual contact, or sneezing, or shaking hands.  Infections occur most often during the warm spring and summer months, but can happen throughout the year.

One of the major ways of avoiding the chance of developing Lyme disease is to avoid being bitten by an infected tick.  Ticks lie in wait on the ends of blades of grass, and can sense the body heat and movement of warm-blooded animals nearby.  Female ticks need blood meals from mammals in order to have enough protein for egg production.  By reducing the number of ticks present around your house, as well as their preferred habitat, you can go a long way in preventing infection.   Keep grass trimmed to avoid overgrowth and long stems, which can reach the level of unprotected skin on your legs, especially if you like to wear shorts during the summer (which I do).  One technique that I am looking forward to putting into practice is having chickens patrol the yard, searching for ticks, as well as other nuisance invertebrates, to attack and devour.  If you are looking for poultry that is even more selective for ticks, based on reputation, guinea hens, and Muscovy ducks are your fowl.  The logic behind these organic means of control is that, if there are no ticks in your yard to bite you or your pet, then there is no chance for either one of you to develop Lyme disease.  (And you get delicious eggs and meat as a bonus!)

Outside of your yard, a major risk factor for being bitten is walking in tick-infested areas with bare skin.  Therefore, when walking through tall grass or wooded/brushy areas, we should all wear loose-fitting, long-sleeved shirts and pants, preferably tucked into our socks.  (I know, it isn’t the most attractive fashion, but it does help detract ticks too, and is a lot better than the alternative.)  After that walk in the woods, we need to check ourselves and our loved ones for ticks from head to toe also, in order to remove them before they bite and start taking their blood meal.

In addition to ourselves, we need to check our pets for ticks also when they come in the house because they could be harboring stowaways that may drop off and latch on to you at a later date.  And we want to remove any attached ticks from our pets too since they can also be infected by Borrelia.  There are many effective chemical tick deterrents for dogs and cats that help protect against flea infestation also, which are applied to the skin and mix with the body oils.  These can be discussed with, and obtained from, your veterinarian, and are a good way to help protect your pet from unnecessary suffering.  Another way to help protect against suffering from Lyme infection is to have your pet vaccinated against Borrelia.  Since they are more likely to carry ticks into the house, vaccination will help prevent infected ticks from passing the disease on to your pet, and will in turn help protect you.

But for the unfortunate victim who is bitten, the tick will feed until it is engorged, growing several times its original size.  If you are able to identify and remove it before a day or so, there is a much lower chance of being infected with the bacteria.  Whether it is on you, a family member, or a pet, here is a quick, simple way to remove a tick.  It isn’t pretty, but it saves you a trip to the doctor or vet, and most of us have probably already done it.

Simply take a nice, well-articulated set of tweezers, and grasp the tick as close to the skin as you can.  As you have probably read in several locations, don’t use a match or something else to “help encourage” the tick to disengage itself.  It doesn’t work, because the tick is actively inserted into your skin at the point of feeding, and its instinct is to burrow down further in response to stress or injury.  Instead, grasp the tick firmly as close to the skin as possible (below the legs, which are probably squirming at this point), take a deep breath, and pull in a sharp, clean motion.  Try not to squeeze the back of the tick, which is full of digested blood, because it’s a pain to clean up.  If you have done everything correctly, you’ll be the proud owner of a live, disgusting, squirming tick.  Dispose of it at your leisure, and according to your comfort level.  (I prefer either flushing it down the toilet or placing it inside a napkin and squishing it outside.  Eventually, I’ll feed it to the chickens.)

After you have removed the tick, however, you need to watch the bite site for a couple of days to make sure that it does not appear infected.  I like to put some triple antibiotic ointment and a bandage over the bite to try to prevent an infection from coming into the wound.  If the area becomes infected, though, it will turn red, warm, and usually painful, and there might be pus coming out of the bite itself.  At this point, it is best to have the area checked out by a doctor to see if medicines are needed.

For the first several days to two weeks after the tick removal, if the tick did transmit the bacteria, the infection will be localized at the site of the tick bite.  The classic finding everyone looks for in Lyme disease is the “bull’s-eye” or “target” rash.  The immediate bite site is red, surrounded by an area of clearing, and then a red border.  But don’t be surprised if you do not see it.  In almost one-third of diagnosed Lyme disease infections, patients do not have this rash or even notice a tick or bite.  Once in the bloodstream, the Borrelia bacteria travel throughout the body and attack numerous tissues.  Other symptoms of early Lyme disease are nonspecific and include fever, malaise, headache, and muscle aches – very similar to having the flu.  So, if you or a loved one has some of these symptoms, but did not notice the rash or tick, you still might be infected, especially if you are in tick-infested areas and are susceptible (which is pretty much anyone who spends a significant time outdoors).

These early cases of Lyme disease should be diagnosed and treated quickly because this will help prevent future complications and suffering.  The best test for diagnosing Borrelia infection is to check for blood antibodies against the bacteria.  Interestingly, this same test is done for both people and animals, such as dogs, that are suspected to be infected.  The doctor or veterinarian will also ask about the history of the disease – when the symptoms started and what they were, where you were when you noticed them, was a tick ever seen, was there a rash, and was there any time outside?  The treatment for Lyme disease in the initial phase is oral antibiotics like doxycycline or azithromycin.

Another classic symptom of early untreated Lyme disease is facial paralysis.  It is not as common as the rash or flu-like symptoms, but seeing it should prompt investigation for Lyme disease.  This finding happens because the Borrelia bacteria interrupt the nerve signals from the brain to the facial muscles.  The facial palsy, or weakness, presents as a drooping lip edge, sagging cheek, and the inability to close the eyelid or furrow the forehead on the affected side.  It can be confused with stroke-like symptoms (which also can have a sagging lip, but does not usually include the eyelid or forehead).  Rarely, it can affect both sides of the face simultaneously.  It is also treated with the same antibiotics, but the facial palsy takes several months to get better.

Hopefully, the infection will be diagnosed and treated at these stages.  However, some people are not as fortunate.  For these poor patients, the bacteria will continue to attack body tissues.  In the next several months after infection, most of the symptoms result from nervous system derangement.  This includes inflammation around the brain, known as meningitis, which presents with neck stiffness, sensitivity to light, and headaches.  It can also cause mild inflammation of the brain itself, or encephalitis, with memory loss and depressed mood.  Diagnosis of Lyme meningoencephalitis requires a lumbar puncture, where cerebrospinal fluid is collected by a needle from the spinal canal (with a technique similar to an epidural for pregnant women) and tested for the presence of Borrelia.  At this point, the treatment is still with antibiotics; however, since it is now infecting brain tissue, the medicine must be of an intravenous form.

For those who suffer for years from prolonged infection without treatment, the Borrelia bacteria can ravage the body, and will result in more extensive and severe neurological disorders, like encephalitis – sometimes to the point where people develop cognitive problems and psychological disorders.  Untreated sufferers can even act like they have psychosis and can be misdiagnosed as being schizophrenic!  The bacteria attack numerous nerves throughout the body, known as polyneuropathy, and can lead to muscle weakness, difficulty walking, dizziness and vertigo, continued facial palsy, and problems controlling bladder function.  Lyme arthritis can devastate the knee joints as a result of the Borrelia bacteria causing inflammation and damage to the cells lining the joint capsule, leading to decreased lubrication and severe joint pain.  Antibiotics are again the mainstay of therapy but are usually less effective in reversing the damage done by long-standing infection.

Another illness associated with Lyme infection is a long-standing disease that persists even after antibiotic therapy.  The prevailing theory behind “chronic Lyme syndrome” is that the bacteria use molecular markers on their cell surface to “blend in” with normal host tissue.  This is known as molecular mimicry.  The problem arises when the immune system – the body’s defense network – starts to recognize the bacterial molecules as foreign, as well as the similar host proteins.  At that point, the immune system starts to attack the host proteins and tissues, resulting in inflammation and cellular damage in the absence of the Borrelia infection.  While there is currently a lot of controversy behind this theory, several observations seem to suggest that some form of molecular mimicry is at work, producing these chronic symptoms.  Evidence includes the persistence and progression of arthritic changes, even after rapid diagnosis and prompt treatment.  This autoimmune reaction may also play a role in progressive neurological symptoms reported by some patients, such as memory difficulties and changes in mood.  However, at the time of this writing, these are all theories, and the established medical and scientific communities do not formally recognize “chronic Lyme syndrome” as a separate diagnostic entity.  From the perspective of the medical establishment, especially the infectious disease sector, once antibiotic therapy is completed, Lyme disease is effectively treated and eradicated.  However, based on my personal experience and anecdotal evidence, I feel that there is more to the story, but only time, and further research, will tell who is right, what is happening, and what the effective treatments will entail.

Whew!  So there you have it – an introduction to Lyme disease.  I know – that was a lot of information!  But here are some final points I would like to summarize and emphasize for you.  First of all, Lyme disease is a bacterial infection transmitted to people and animals by a tick bite.  It is classically associated with rash and flu-like symptoms, and less often with facial weakness and other neurological symptoms.  Prompt treatment with antibiotics will cure the majority of cases.  Preventing tick bites, both for you and your pets, is very important in reducing your overall risk of becoming infected.  And learning how to properly remove a tick in a safe and expedient manner will also reduce the chance of suffering from this disease.  I hope now, with this information in hand, we can continue to enjoy our rural lifestyle and outdoor pursuits, but with a better respect and understanding of the potential dangers, and how to avoid them.

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Herbal medicine can seem intimidating, but the remedies are broken into the general categories of adaptogens, aromatics, astringents, bitters, nervines, carminatives, diaphoretics, emollients, expectorants, and tonics.  Several herbs are in multiple categories so, to make things simpler for the beginner or busy homesteader, it is best to think about the health issues that are common to your household.  If your family is prone to the flu, those are the herbs you need to know and grow.

Most herbs can be enjoyed as tea.  This is the mildest remedy and, generally speaking, you can enjoy as many cups of tea as you want.  A secondary benefit of taking your medicine as tea is that you are also drinking water.  Basic hydration can in itself solve a multitude of health problems.  To make tea with fresh herbs, put a handful of clean herbs in a pot.  Pour boiling water over the herbs, cover, and let steep for 3-5 minutes.  Add honey to taste.

Adaptogens are herbs that can be used regularly to help us handle stress.  These herbs can be either stimulating or relaxing, but all adaptogens work to support the body as a whole.  Some of the more common adaptogens include ashwagandha, chamomile, both American and Asian ginseng, and rhodiola.  Chamomile, ashwagandha, and rhodiola are relatively easy to grow.  Chamomile is the simplest to prepare, and ashwagandha and rhodiola are high-value crops that will do well at farmers’ markets.

To make chamomile tea, you use the flowers, but to use ashwagandha you need to use the dried root.  Simply harvest the roots, wash and cut them into small pieces, and place them in a dehydrator or your oven with the pilot light on.  The root will become very brittle when completely dried.  To make a simple ashwagandha tea, you can simmer one teaspoon of the dried root in one cup of water for 20-40 minutes, depending on the strength desired.  Using a coffee grinder, you can also powder the roots and combine them with other herbs such as ginger or cinnamon.

Aromatics have strong aromas and are the foundation for aromatherapy.  Taken internally, they provide relief and support for the digestive, reproductive, and respiratory tracts.  Aromatics include angelica, cardamom, fennel, ginger, peppermint, and rosemary.

Astringents dry or shrink tissue and can be used either topically (for splinters) or internally, to tone mucous membranes and dry up excess phlegm.  Astringents include agrimony, blackberry root, and leaf, green or black tea, rose, witch hazel leaf and bark, and yarrow.

Bitters are not very tasty, as their name implies, and are most often used in a tincture.  Just a drop or two on the tip of the tongue is enough to encourage the production of gastric juices which stimulate appetite and digestion.  Artichoke, dandelion, gentian, and orange peel are good bitters.  Tinctures are the strongest form of herbal medicine.  A tincture is a concentrated distillation of herbs, usually in 80-100 proof alcohol.  If you are avoiding alcohol, you can make tinctures with glycerin.  For information, including recipes, read How to Make Herbal Tinctures.

Nervines are a category of herbs that supports the nervous system.  These herbs help with worry and are also good for the occasional sleepless night.  Chamomile, California poppy, hops, and lavender are gentle nervines to try.

Carminatives are herbs that aid digestion and reduce or prevent gas.  You can add them to food or herbal tea.  Excellent carminatives include angelica, anise, caraway, chamomile, fennel, ginger, and peppermint.

Diaphoretics help raise your body temperature to make you sweat, stimulating circulation.  They also cool the body through increased perspiration.  This is the category of herbs you turn to for fevers.  The herbs include cayenne, elderflowers, garlic, ginger, linden, and yarrow.

Emollients are to be used externally for wounds and burns. For information on the benefits and preventative uses of herbal-based skincare, I recommend reading Grow an Herbal Skincare Garden: 7 Easy-to-Grow Herbs for Skincare.

Emollients, such as aloe vera, chickweed, comfrey, marshmallow, and violet, are used topically to soothe and protect skin.  These herbs can be added to a salve, lotion, or handmade soap.  As you already know, aloe vera can be split open and applied directly on a scrape or burn.  A comfrey poultice immediately relieves some of the pain of a bad scrape or sunburn.  Comfrey contains allantoin, a substance that helps the formation of new skin cells while reducing inflammation.  To make the poultice, roughly chop a handful of large comfrey leaves and mix in the blender with a half cup of water until you have a liquid.  Add ¼ – ½ cup of flour and blend until you have a paste.  Fold a clean dishtowel or cheesecloth in half lengthwise and spread the comfrey paste on the cloth. Apply to the affected area and secure the poultice with an ace bandage.

Oxymels (made with vinegar, herbs, and honey) and syrups are the next steps up in herbal remedies. You can find a lot of good information about oxymels, including how to make them here: Making Oxymels: The Sweet-Tart Medicine.  Expectorants encourage productive coughing.  You can make cough syrups or oxymels with elecampane, horehound, licorice root, slippery elm, or violet leaf.  It is worth the effort to buy raw honey from a local beekeeper, as raw honey that is local to your area is extra beneficial for seasonal allergies.

Finally, tonics are nutritive herbs that can be consumed daily to keep your body systems strong and healthy.  Dandelion, hawthorn, milk thistle seed, moringa, and nettle leaf are all excellent tonic herbs.

Growing, harvesting, and using herbs on your homestead for medicinal purposes is not as difficult as you may have thought.  In addition to the healing properties of herbs, it is a good feeling to know you have the resources to care for yourself and your family when they are under the weather.

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My wife’s grandfather suffers from advanced dementia, probable Alzheimer’s type.  He was once a vibrant, healthy, strong man who loved to work outdoors.  He actually built his own house and cabin on the lake, worked on his vehicles, and planted an orchard and a garden that spanned one acre on the lower lawn!  My wife tells me of better times, when the family would go to the cabin, or when they would all get together for Christmas, and her grandfather would be so happy and mischievous.

I wish that I could have met that man.  I wish I could have talked with him about all of his experiences, learning from his real-world wisdom and skills.  That is not the case, though.  Now he is confined to a hospital bed in the living room, requiring constant care by his wife and visiting nurses.  This once vibrant, independent man now sits or lies there most days, entertained by the television.  He usually sings or talks to himself – short phrases, or one or two words that sometimes trail off into gibberish.  He is fully reliant on others for all of his needs – feeding, clothing, bathing, toileting.  His wife, who suffered a stroke herself several years ago that affected her mobility, now must care for the both of them.

The stress it has placed on both their lives is indescribable.  He has mood swings, and erratic sleep patterns.  She is lucky if she gets five or six hours of sleep a night.  He is more prone to infections, which, in his state, can hit him hard and worsen his fragile neurologic state.  I see in my wife’s eyes the hurt and sadness, looking at the dramatic transformation from what her grandfather was to the condition he is in now.

Dementia is a condition of pathologic neuronal cell death, which leads to memory decline, as well as behavioral changes.  There are several types of dementia, with the most common being Alzheimer’s.  This condition was described at the turn of the last century of the neuropathologist for which the disease was named, in a nun with precipitous memory and cognitive decline.  Dr. Alzheimer showed on pathologic sections of the patient’s brain that the overall volume had declined, and staining of microscopic sections revealed abnormal protein aggregates, known as plaques and tangles.  It is a disease of the elderly, classically manifesting symptoms after age 65.  However, there are several known genetic mutations and conditions which predispose individuals to the disease at a younger age.  The cardinal feature of early Alzheimer’s disease is memory difficulties, out of proportion to other neurologic findings, such as weakness, or abnormal movements.

A very good resource for patients with early memory difficulties, as well as loved ones, is the Alzheimer’s Association website.  It contains a great deal of useful information regarding the disease itself, as well as resources and links for caregiver support.  It also contains more in-depth examples and descriptions of disease stages and symptoms than what I am able to present below.  The following discussion is an overview of the stages and initial symptoms of Alzheimer-type dementia (I state it this way because, currently, the only way to have clinically proven Alzheimer’s disease is through confirmed pathology, which requires microscopic brain tissue sectioning.  This is usually only performed at autopsy.)  I highly encourage you, if you are interested in the disease or diagnosis, to consult with your medical care provider, as well as obtain more information from reputable sources.

There are seven recognized stages of progression in Alzheimer’s dementia.  Stages 1 and 2 are also seen in normal individuals as they age, and are not specific for pathology.  Stage 1 is normal function, or no impairment.  In Stage 2, people suffer from very mild memory lapses, such as forgetting words or misplacing objects, and may recognize these errors.  However, no abnormalities are described by friends or family, and formal evaluation does not elicit any deficits.

Everyone wonders from time to time whether his or her, or a loved one’s, forgetfulness is normal or a sign of something more ominous.  The overarching difference between normal aging and “senior moments,” and dementia is whether the symptoms or difficulties impinge on daily activities and quality of life.  That being said, there are several red flags that should prompt further questions, and perhaps a conversation with a physician, if noticed in yourself or a loved one.  The first are memory changes that disrupt the daily routine, which point to difficulty recalling and retrieving recently learned information.  Symptoms of concern include forgetting important dates or asking the same question repeatedly.  Another manifestation is difficulty with orientation – people suffering from early dementia lose track of time, and may not remember how they got somewhere, or where exactly they are.  This leads to confusion, and patients can become easily lost, even in familiar locations.  People with early dementia also misplace objects in unusual locations (i.e., putting their keys in the fridge), and not being able to retrace their steps to find the object.  Now, everyone forgets names or appointments, or misplaces objects from time to time, however; normally, we end up recalling the information, or remembering where we left the item, a little later (which has happened to me on numerous occasions, much to the chagrin of my wife!).

Another realm of cognition that is affected early by Alzheimer’s dementia is problem-solving, planning and mood, which all localize in the brain to the frontal lobes.  For example, a person who could normally cook from a recipe or handle their own finances has difficulty concentrating or completing the task.  This does not include the occasional math error, though, which we all do from time to time.  Early dementia also leads to impairments in decision-making, making people more impulsive than usual.  They may also pay less attention to personal hygiene and grooming.  In addition to attention, however, hygiene may be due to worsening depression or apathy, a result of the disease affecting personality and mood.  People can also become suspicious (sometimes to the point of paranoia, but not classically early in the disease), fearful and anxious.  They have difficulty controlling their emotions, becoming upset more easily and having outbursts of anger or crying.  These emotional disturbances, combined with difficulty dealing with new or unique situations, and trouble with memory and concentration, can all cause people with early dementia to give up social situations they used to enjoy, such as work or hobbies with friends.

Stage 3, also known as mild cognitive decline or impairment (MCI), is the initial phase of early-stage Alzheimer’s in most individuals.  However, even then, not all patients who present with MCI will progress to full-blown Alzheimer’s.  It is a risk factor, though, with 15% of MCI patients per year going on to developing Alzheimer’s dementia.  In this stage, loved ones start to notice difficulties in memory retrieval and recall.  Patients also demonstrate difficulties planning and organizing activities or tasks that they were capable of performing before, such as shopping for groceries or managing their checkbooks.  Detailed medical interviews, using screening tests such as the Mini-Mental Status Exam (MMSE) or Montreal Cognitive Assessment tool (MoCA), usually demonstrates deficiencies.

Stage 4 is known as mild Alzheimer’s disease, and includes forgetting recent events, as well as some personality changes, classically becoming more depressed and withdrawn.  Medical interviews will detect deficiencies in concentration, attention, and memory.  Stage 5, or moderate Alzheimer, shows evidence of memory deficits and cognitive functions readily in everyday life.  Patients need help at this stage with activities of daily living (ADLs).  More glaring omissions are present in recalling personal history, as well as difficulty with important contact information, such as their address and telephone number.  They may need help choosing clothes appropriate for the weather (since they have difficulty with the passage of time), but they do not need help feeding themselves or using the bathroom.  Remote personal memory, such as important Christmas parties, close family members, and signature details of their lives, are also still intact at this stage of the illness.

The final two stages of Alzheimer disease (6 & 7) see a more precipitous decline in memory, attention, and function, especially after the individual becomes less mobile or bed-bound.  In Stage 6, there is severe decline, dominated by personality changes.  This is perhaps one of the most difficult aspects of this illness, both for the family to experience, and for the physician to treat.  The patient becomes much more suspicious and delusional, in conjunction with losing the ability to recognize their loved ones and caregivers and severe memory disturbances.  It is a cruel irony, then, that this is the stage where an individual becomes much more reliant on family members and caregivers for assistance with ADLs, such as using the bathroom (there is difficulty controlling bladder and bowel function, with frequent incontinence) and remembering to eat.  If still ambulatory, he or she becomes easily lost.  There are also significant aberrations in the sleep-wake cycle, so an individual will wake up during the night, become even more confused and disoriented, and wander off.

Late-stage Alzheimer’s finds the patient totally bedbound and reliant on others for help with every aspect of care.  They have lost the ability to respond meaningfully to their environment.  In addition, they have “forgotten” how to control their limbs, and even use their tongue to initiate and facilitate swallowing.  Muscles and limbs grow rigid and atrophic from disuse.  Patients must be constantly repositioned and turned every couple of hours to avoid bed sores, which can become infected, especially those on the buttocks or hips.  Aspiration of foods and liquids during feedings is a major concern, since it can lead to pneumonia.  The average duration from diagnosis of early Alzheimer’s to end-stage disease is about seven to ten years.

Unfortunately, there is no definitive laboratory test or imaging study that conclusively diagnosis Alzheimer’s disease.  Diagnosis is made through taking a thorough history, as well as complete neurologic and cognitive exam and assessment.  Another very important part of the evaluation is the history and observations obtained from family members.  Blood work and imaging studies are crucial steps in the initial evaluation, because they can help identify potentially reversible causes of memory loss and dementia.  While they are not common, these causes, since they are reversible, need to be identified, or excluded.  Reversible causes include hypothyroidism, vitamin B12 and folate deficiency, chronic subdural hematoma, and drug reactions, especially sedatives and narcotics.

Currently, there is no cure for Alzheimer’s dementia.  Treatment consists of symptom management, and includes both behavioral therapies and medications.  Learning the utility and rationale behind these treatments can help alleviate some of the stress and confusion, for both the patient as well as the caregiver.

Behavioral management helps to provide a non-threatening environment that makes the patient feel comfortable.  It should also help to reduce episodes of agitation and confusion.  It involves creating a calm atmosphere.  Caregivers should try to use short, positive statements, not raising their voice, or taking offense at outbursts.  The environment should also avoid too much loud sounds, lights, or background “noise” – distractions that can further confuse or aggravate the patient.  Patient comfort should also be monitored closely.  In addition to avoiding bed sores and uncomfortable positions, patients should also be monitored to make sure that they are not suffering from constipation or urinary retention, which can be very painful if left untreated, and are easily overlooked.

The mainstay of Alzheimer medications is cholinesterase inhibitors.  The rationale behind these treatments is the finding that the cells that produce acetylcholine, an important neurotransmitter in the brain involved in, among other functions, memory and thought, are damaged in Alzheimer’s dementia.  Cholinesterase inhibitors work by slowing the breakdown of acetylcholine by particular enzymatic processes.  This allows the neurotransmitter, which has reduced levels in the Alzheimer’s brain, to stay around longer and facilitates its signaling function.  The hope is that the delayed breakdown will help augment signaling, and ultimately memory and thought.  These medications are usually well-tolerated, especially when started at a low dose and titrated slowly.  The major side effects involve the gastrointestinal tract (which also uses acetylcholine for signaling), resulting in nausea, vomiting, loss of appetite, and diarrhea.
A newer medication on the market is memantine.  It is another class of Alzheimer medicine that affects brain neurotransmitters, and works to modulate glutamate activity in the brain.  A lot of research has shown that glutamate is involved in memory formation and retrieval.  Too much glutamate produces conditions that are toxic to the neurons, however, and memantine is thought to work by protecting cells from glutamate neurotoxicity.  Both of these medication classes – memantine and cholinesterase inhibitors – need to be prescribed and monitor by a licensed medical professional.  Please seek their input, and medical evaluation, if there are any problems or concerns about starting or continuing any of these medicines.

Several other classes of drugs are used for additional symptom management.  These include antidepressants for mood and irritability, as well as antipsychotics for hallucinations and agitation.  It is important to note that these medicines do not work on the underlying pathology of Alzheimer’s, as the former compounds.  Rather, they are specifically tailored to address the symptoms noted.  As with all medicines, these therapies should be started at \the lowest possible dose, and only one at a time to avoid harmful side effects.  Elderly patients have slower metabolism of chemicals in general, and are more sensitive to medicines, particularly ones that affect cognition.  As the old mantra in medicine goes, “start low, and go slow.”

One medication that should be avoided by elderly individuals, especially those suffering from dementia, is diphenhydramine, the active ingredient in main over-the-counter antihistamine agents, as well as several popular sleep medicines.  While usually safe and effective in a majority of the population, there is an increased tendency for insomnia, agitation, and confusion in older patients.  These side effects of diphenhydramine occur because it crosses into the brain and affects acetylcholine neurotransmitter activity, which, as you recall from earlier, is already aberrant in Alzheimer’s disease.

Finally, one topic that is particularly important to me, and one that is overlooked, is caregiver health and stress management.  Spouses and family members who help support and care for their afflicted loved one make untold and incalculable sacrifices –time, sleep, careers, friends, hobbies –  all for love.  But as giving and selfless as these people are, it must be remembered that everyone is human, and everyone can become burnt out also.  The stress and sadness of a chronic progressive disease take their toll on our patience, our moods, our mental and physical reserves.  Grieving is an important part throughout the whole process; guilt feels like an unwanted cloud hovering over every thought.  It is natural to grieve since Alzheimer’s slowly takes away the person you love.  That is perhaps the worst, most cruel, most monstrous part of the disease.  Guilt can arise as the feeling of stress and difficulties coping with the memory loss or agitation, the mood swings, \the sleep disturbances, and eventual dependence.  It might be cliché, but it is important to say: “It’s not your fault.”  Everyone feels these feelings, especially with the depression, the stress, the insomnia.  It is important to seek out support and resources (family, friends, and community) in order to manage the situation and handle the stress.  It is also vital to learn about dementia, as well as caregiving techniques.  Hopefully, that is what you have been doing throughout this article.  Other resources are available online, as well as through your health provider.

Preventive Medicine: What You Need to Know

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Carbon monoxide is a colorless, odorless, tasteless gas that is highly poisonous. It is the product of incomplete combustion of organic matter, produced in the setting of an inadequate oxygen supply. Classic sources include older combustion engines without catalytic converters and other gasoline-powered equipment, especially in an enclosed setting, as well as heaters, some ovens, and poorly sealed or ventilated fireplaces. Since it is completely undetectable by smell or taste and does not cause any irritation when inhaled, the gas can build up in a space quickly to highly toxic levels. By learning and identifying the sources of production, as well as signs and symptoms of poisoning, treatments, and, most importantly, prevention, I hope to help educate you in order to avoid unnecessary injury or suffering.

But before that, I would like to present a general disclaimer regarding this article. The information presented here is for educational purposes only. I am giving you general medical symptoms and classical cases for your understanding. This is not for diagnosis, and certainly not for treatment. If you are suffering, or even if you are fearful that you are suffering, from any of the symptoms listed below, you MUST SEEK PROMPT MEDICAL ATTENTION. I want to impress on you the severity of carbon monoxide poisoning, and educate you as to what the signs and symptoms of toxicity are and might represent. It is up to you, however, based on your level of concern to act on that information in your particular circumstance. But after reading more about carbon monoxide poisoning, I hope that you will at least call a medical professional to explain your symptoms and get more information and instructions. If any doubt enters your mind, and you are worried about you or your loved ones’ health and well-being – please, please, please – go to an emergency room for evaluation and care. In life, and especially in medicine, it is always better to be safe than sorry, especially, as you will see, in this condition.

Dangers of Carbon Monoxide in Rural Areas

Now, with that aside, let us return to our topic. In terms of pathology, carbon monoxide has its negative effects by competing with oxygen for the binding sites on hemoglobin (which has four sites to bind oxygen), forming a compound known as carboxyhemoglobin. Hemoglobin is the protein in red blood cells, or erythrocytes, which carries oxygen from the lungs and to the body. When compared with oxygen, the bonding affinity of carbon monoxide to hemoglobin is approximately two hundred times stronger. In addition to displacing oxygen, the carboxyhemoglobin also makes it more difficult for oxygen to be released from the other hemoglobin binding sites when the red blood cell arrives at the recipient tissue.

Through these mechanisms, it inhibits oxygen transport from the lungs to the body. Unlike other causes of hypoxia, however, where patients have a dusky or bluish (cyanotic) appearance due to the absence of oxyhemoglobin, in carbon monoxide poisoning the oxygen is trapped in the hemoglobin molecule and carboxyhemoglobin is itself a bright-red color. Classically, it has been noted that patients suffering from toxicity can appear rosy-cheeked and have a healthy-looking appearance. In essence, however, regardless of appearance, carbon monoxide starves the body tissues of oxygen, leading to pathologic signs and symptoms of ischemia.

The central nervous system, which includes the brain and spinal cord, and the heart are particularly sensitive to hypoxic conditions, and are predominantly affected by carbon monoxide poisoning. Acute side effects can occur within minutes to hours after exposure, depending on the concentration of carbon monoxide and the condition of the patient. Mild symptoms that can occur from minimal contact with the toxic gas include headache, dizziness and fatigue. Unfortunately, these are fairly nonspecific symptoms, and are often mistaken for a viral illness initially, especially during the winter months, when people are predisposed to exposure. In addition to illness, carbon monoxide symptoms can also be confused and misdiagnosed, depending on the presentation, as chronic fatigue, depression, or even migraine. At higher concentrations, carbon monoxide can cause confusion, altered sensorium, nausea and eventually coma and death, if not recognized, reversed, and treated in time.

A major concern with acute carbon monoxide toxicity is its effect on the nervous system. Besides headache and fatigue, poisoning can impede higher intellectual functions, such as memory formation, and can also cause irritability. More chronic symptoms, which occur less frequently, but can be permanent, depending on duration of exposure, include amnesia, abnormal gait, dementia, and even blindness. Depression is another major concern in acute poisoning and can present in up to half of victims even a month after exposure. Older individuals, those who have lost consciousness when exposed to carbon monoxide, and people who have pre-existing neurological problems, such as a prior stroke or seizure disorder, are at increased risk for further neurological injury.

Another group that is very susceptible to carbon monoxide poisoning are developing fetuses. Since the carbon monoxide keeps oxygen from being released from the hemoglobin molecule, it hinders transport from the mother’s lungs to the developing baby in the womb. Carbon monoxide can also cross the placental barrier itself, and cause direct effects on the fetal hemoglobin, which has an even higher affinity to it than adult hemoglobin. So even in mild maternal exposures, the fetus can experience significant toxicity, since elimination from the fetal tissue is slower than in adults. All of these factors result in profound fetal injury and death and makes it very important to monitor and avoid this situation if you are pregnant.

Since carbon monoxide poisoning can mimic many of the signs and symptoms of other diseases, it is very important to at least think about it if the circumstances and symptoms are present and compatible. In terms of history, the most important factor is the potential exposure to a source of the gas. Classically, more poisonings occur during colder seasons, like fall or winter, and among lower socioeconomic classes, since people are inside more often in enclosed spaces with a heat source, such as a space heater, oven, or fireplace. Garages are also another area of potential exposure, since automobile exhaust contains significant concentrations.

If you think that either you or a loved one is suffering from carbon monoxide toxicity, you need to vacate the area at once and seek medical attention. Immediate concerns are for people at-risk who are still in the area of exposure, as well as emergency response personnel, who may be put in harm’s way during a potential rescue attempt. That is why you must call 911 and wait for trained personnel with proper equipment (oxygen tanks and masks) to arrive. You do not want to become another victim. If it is at all possible, however, without endangering yourself, try to ventilate the area, to reduce the concentration of carbon monoxide, and, if you can (usually not, but just a point to consider), try to shut off or stop the source of toxicity.

Initial treatment, which is usually administered by EMS and continued in a hospital setting, is one-hundred percent oxygen. Confirmatory diagnostic testing, in addition to symptoms and an identifiable carbon monoxide source, is also made at the hospital using a carboxyhemoglobin saturation monitor. The monitor calculates the differences in arrival time between reflected light waves emitted by the device. These differences correlate with the amount of carboxyhemoglobin relative to oxyhemoglobin present in the blood.

Now just as interesting, and important aside – cigarette smoke, in addition to all the other numerous carcinogens and toxins, also includes carbon monoxide. This can lead to blood concentrations up to twice the level of normal, and should be kept in mind when a patient is interviewed and treated. Standard pulse oximeters, which are present in most emergency rooms and hospital floors, cannot accurately measure the difference between the two molecules, and falsely report a normal or even elevated level of oxyhemoglobin in the bloodstream. It should be noted that people arriving with the symptoms and a history consistent with exposure to carbon monoxide, who have normal carboxyhemoglobin levels, may still have been exposed. They should still be treated as if they were suffering from carbon monoxide toxicity, especially if the patient is pregnant. By giving pure oxygen, the increased concentration helps compete with carbon monoxide for hemoglobin binding sites. It actually reduces the half-life of carboxyhemoglobin by a factor of four. However, it must be remembered, as stated earlier, that pregnant women need to be treated longer than other patients due to the increased susceptibility of the fetus.

The mainstay of therapy for carbon monoxide poisoning is hyperbaric oxygen. In this treatment modality, patients are placed in a hyperbaric chamber and subjected to several times greater atmospheric pressure than normal in the setting of one-hundred percent oxygen. The pressure chamber is essentially the same as that used in treatment for nitrogen gas toxicity (also known as decompression sickness or “the bends” for divers) except that the increased pressure is the main therapeutic factor for decompression sickness. On the other hand, it is thought that hyperbaric treatment with oxygen helps to dissociate the carbon monoxide from the hemoglobin molecule even faster than oxygen at normal atmospheric pressure. It may also help supersaturate the bloodstream, and facilitate the transport of oxygen to the tissues in the blood plasma itself, bypassing the poisoned hemoglobin molecule. Other than increased oxygen concentrations, there is no other specific treatment for carbon monoxide poisoning. The rest of the medical care consists of supportive treatment, which is essentially managing other symptoms, such as respiratory distress, hypotension and neurologic damage.

Perhaps the most important piece of information regarding carbon monoxide is prevention. Detection is the key to avoiding injury or death, and staying out of the hospital or needing hyperbaric treatment. Public health measures have come a long way in educating the public about the risks and symptoms associated with toxicity. It has become the law in many states that houses be equipped with carbon monoxide detectors, in addition to smoke detectors. Both of these detectors save lives, and they should be on every floor of a home.

Carbon monoxide poisoning is insidious and claims too many lives every year. In order to protect yourself and your loved ones, it is important to learn the source of the gas (faulty combustion sources, such as engines or fireplaces), as well as the classic symptoms. Unexplained headache, fatigue, nausea, depression, and confusion should prompt questions and investigation, to make sure that chronic poisoning is not occurring, especially in pregnant women. And, most crucial, carbon monoxide detectors need to be in every home, in order to warn and protect against poisoning, keeping us safe as we enjoy those quiet evenings by a roaring fire.

The post The Dangers of Carbon Monoxide: Even Rural Residents Need Fear This Invisible Killer appeared first on Homestead.org.

But, where do we begin?  “What can I, without a lick of medical training, and no knowledge about medications, diseases, blah, blah, blah, do?” you ask.  Everything!!  Each individual has a responsibility to take care of his or her own body as best as they can.  Yes, there are some unlucky individuals who have very serious diseases that they are born with, and which require constant invasive high-tech medical care.  But that is not the majority of people.  The vast majority of us would not neglect our vehicle if it needed a basic tune-up or simple repairs to keep running, or clean and maintain our house to keep it from becoming dilapidated.  We need to have the same approach to our own bodies and health.

And we know some of the stuff that we need to do—eat a healthy, well-balanced diet that is low in fat, full of fruits and vegetables, low in empty calories, like those from processed sugars and saturated fats, and salty packaged foods.  Exercise regularly.  The information bombards us on the television, radio, Internet, blogosphere, newspaper (if you still get one).  I have trouble with this stuff too, but it is important to stick with, struggling to avoid that fifth chocolate chip cookie, or big bowl of chocolate ice cream, just because we are bored (excuse me a moment).

Now, where was I . . . oh yeah, health matters.  Preventive medicine is a term that is very in vogue nowadays.  But I’m not sure if everyone knows exactly what it means, or what it encompasses.  Simply stated, preventive medicine is the practice of medicine that is aimed at trying to reduce the overall risk of someone developing a disease or condition later.  For example, a classic form of preventive medicine is getting a vaccination to avoid developing a viral infection, such as mumps.

This approach to medicine is very beneficial, on several fronts.  First and foremost, it can reduce some of the unneeded suffering caused by certain diseases.  Controlling or avoiding several risk factors, which is another main thrust of preventive medicine and which will be discussed in greater detail in a little while, can greatly reduce your risk of having a heart attack, stroke, and even cancer.  But these three examples are also multifactorial diseases, or illnesses that have more than one cause.  While there are factors that you can manage to reduce your risk, there are others—like age, gender, and genetics—which are fixed, so your risk can never be zero.  Preventive medicine also helps to empower the patient (you and I) in some of the medical decision-making (how I exercise, or eat, and that I don’t smoke at all or drink excessively), so that I can try to avoid risky treatments or medicines later in life.  And, I don’t know about you, but I really like having a say in a lot of the decisions I make in life, especially as it pertains to my body.  Finally, preventive medicine helps to reduce huge medical costs, both for you and the hospital.  “So what?” you ask.  “Who cares about the hospital?  They have millions of dollars in their budget to throw around on fancy new equipment and new-fangled designer drugs.  Why should I worry about them saving money, especially since I never want to go there in the first place?”  Well, all I can say is that I hope that you never do have to go there, and, helping to reduce the overall health costs also helps to avoid the medical establishment passing their increased costs on to you, the consumer (if you can afford healthcare, which at the time of this writing, sadly, a lot of people still cannot).

So, what can you do?  What monumental, life-altering, Herculean tasks must we all shoulder in order to avoid something worse?  Well, surprisingly, it is not as difficult as you might first suspect.  Like planting the marigolds in with the vegetables, there are a lot of benefits that come from a couple of simple, straightforward steps.  Perhaps the most difficult step is to understand why we should do these things, and then developing the habit.  Personally, I like to divide the list into two halves:  those things I need to start doing to improve my health, and those things I really should avoid or try to give up.

The first, and most important, thing that I should do—but something I still struggle with—is have a regular appointment with a primary care provider (PCP).  A PCP is someone (internist, OB/GYN, nurse practitioner, physician’s assistant) who routinely (once or twice a year, or more if necessary) evaluates your overall health and makes sure you are reaching specific goals.  They can also refer you to a diverse number of specialists if you have a particular symptom or problem that needs to be addressed.  The PCP is kind of like the conductor of a symphony, with the music being your overall health.  They should know about all of your medical conditions, the list of medications you are taking, and any medical problems you might be predisposed to or at risk for.

The first step that your PCP should perform, after introducing him or herself, is sitting down and doing a complete medical history and physical exam.  This will serve as a baseline of your health, which can be referenced and compared to in the future, especially in emergency situations.  The medical history is basically you telling your PCP all about yourself—how you feel, any aches and pains, past injuries or surgeries, anything you’re being treated for now, all medicines (including over-the-counters, herbs, and supplements), allergies, how much you drink or smoke, where you live, and what you do for a living.  Whew!  It is a lot, I know, and it is personal, but don’t you want your doctor to know that you have a serious allergy to penicillin when prescribing an antibiotic for your pneumonia, or that antihistamines like Benadryl completely knock you out?

The physical exam will consist of taking several vital signs, such as height, weight, temperature, blood pressure, pulse, respirations, and pain score.  It also includes a thorough head-to-toe check of everything—your skin, eyes, ears, nose, throat, listening to your heart beat and lungs, feeling your pulse in your arms and legs, testing your strength, seeing you walk, checking your balance.  The exam is like the test drive for your car, especially a pre-owned car—it’s to make sure that all the systems are in working order, and to see if there is anything to keep an eye on (like that dash warning light which keeps flashing on and off, or that pesky freckle right between your shoulder blades that looks okay right now, but seems to itch every once and a while).

All of this information and examination, then, is very important to know and to track (hence the name vital signs), but I would have to say, especially in our society today, the one that is the most important but most overlooked would have to be the blood pressure.  I know, I know, you were thinking that I was going to say weight, but you know what we need to do about that.  I mentioned it above, I’m working on it too, and I’m not going to beat a dead horse.

Now, let’s move on to blood pressure.  Why would you think that I would feel that these two simple numbers are so important? (Just a footnote: the upper number, the systolic pressure, measures the blood pressure as the heart is contracting, or pushing blood through the body, while the lower number, or diastolic pressure, measures while the heart is relaxed.)  Well, as I mentioned earlier, there are a couple of things that we can do currently to reduce our risk of heart attacks and strokes.  Managing our blood pressure is perhaps one of the most important.  Hypertension, or high blood pressure, is also one of the most dangerous, and insidious, diseases we face in the medical profession. There are no symptoms, no pain, no signs of danger, until it is too late.  I know people say that their vision blurs, or they hear their pulses, or have headaches, or some other symptom.  But these do not always correlate with blood pressure, and your blood pressure can still be elevated, even when you feel completely normal.

Treating hypertension is usually a team effort between you and your PCP.  The diagnosis of hypertension is made after having three successive blood pressure readings above 140/90.  Some people are able to lower and maintain their blood pressure through diet and lifestyle modifications alone.  These consist of limiting or reducing salt intake, diets high in fruits and vegetables, and regular aerobic exercise.  This is tried in all patients for about three months.  If lifestyle modification is unsuccessful, however, then it is usually necessary to talk to your PCP about starting a medication.  There are a lot of choices for antihypertensives, which impact blood pressure differently.  Different people respond differently, and it is important to figure out which medicine is right for you.  But the take-home message about hypertension is that once you start taking a medication—continue taking it—no matter how good you feel.  Hypertension is a silent killer, but with regular follow-ups, monitoring, and medication use, the disease can be managed and many of its serious complications can be avoided.

One other major action you can take, again with your PCP’s help, is to routinely monitor your blood sugar at semi-annual office visits for surveillance, or several times a day if you already have diabetes.  Diabetes is a disease of elevated blood sugar (glucose), resulting from the body’s inability to maintain normal sugar levels because of a deficiency of or decreased sensitivity to the hormone insulin.  Insulin is the molecular key that unlocks many cellular doors to let glucose inside.  Elevated blood sugar has devastating effects on many sensitive tissues, including the brain, eyes, blood vessels, and nerves.  Diabetes is also a risk factor for suffering a heart attack or having a stroke, as well as causing kidney failure, and eventually requiring dialysis (artificial filtering of the blood to remove toxins that normally pass out of the body in the urine).  But with adequate blood sugar monitoring and control, following a diabetic diet, and the proper use of insulin and other diabetic medications, these symptoms can be lessened and complications avoided.

Monitoring and controlling your blood pressure and blood sugar are two powerful ways of keeping yourself healthy and helping to avoid very serious disease complications.  Two other important preventive health measures involve avoidance, in particular, avoiding tobacco and excessive sun.  With these additional habits, you can significantly reduce your chances of developing many different types of cancer.

The first piece of advice is to avoid too much sun exposure.  Now, don’t get me wrong.  I like being outside and working as much as the next person, probably more so than some, since I have to be inside a lot at my other job in the hospital.  What I am saying is not to be a sun-worshipper.  For example, if you plan on a long day of fieldwork, try to wear light, reflective clothing that will cover and protect sensitive areas from sunburns, such as a broad-brimmed hat for your head and face (including the tips of your nose and ears, which we sometimes forget), as well as longer sleeves and trousers for your arms and legs, respectively.  Sunburns are actually skin damage at the molecular, or DNA, level.  The ultraviolet, or invisible high energy, component of sunlight penetrates the top layers of skin and slams into portions of your DNA molecules, knocking out atomic bonds and causing mutations.  Your cells are able to fix some of them, but others cause cell death, leading to the sunburn, which is actually classified as a type 1 or 2 skin burn, depending on if it blisters or not.

Rarely, some of the mutations do not cause cell death, however, but rather let the cell grow and divide uncontrollably.  This leads to skin cancer.  If you are a fair-skinned individual with a lot of moles or freckles, you and your PCP need to regularly monitor your skin for changes that could signal the presence of early skin cancer.  While your healthcare provider can give you more details, and pictures and diagrams are readily available on-line (just look under melanoma and symptoms), it is important to remember ABCD.  This acronym is to help remember that, for each mole or freckle, if there is any change in its Appearance, Border, Color or Diameter, it needs to be looked at by a healthcare professional and potentially biopsied.  Please do not think that it is “nothing” and ignore it.  Skin cancer diagnosed early is very treatable, and there is a high chance of cure if it has not spread outside of the skin.

Now, what I am going to say next is very close to my heart and very personal, too, because I have someone close to me struggling with this particular problem right now.  Stop using tobacco, whether it is smoking cigarettes or chewing it.  If you don’t smoke or chew, don’t ever start.  If you are currently using a tobacco product, and are thinking about quitting, do everything in your power to meet this goal.  If you have tried and failed in the past, try again.  If you don’t think that you need to, consider this: nicotine is one of the most addictive substances known to man.  The substances in cigarette smoke, which include hundreds of carcinogens (cancer-causing agents), are poisonous to blood vessels.  It damages blood vessels in the heart and brain, and is a major reversible cause of heart attacks and stroke.  Smoking has also been linked with numerous types of cancers, including lung and skin cancer.  These are both usually advanced and incurable when they are diagnosed, and the risk of developing them can be dramatically reduced by quitting.  There is a whole laundry list of other health problems linked to smoking, including emphysema, chronic bronchitis, asthma, birth defects, sudden infant death syndrome, problems with circulation and blood clots, and the list goes on.

Chewing tobacco is another dangerous, addictive, unhealthy habit.  I have heard of some patients who quit smoking but started chewing, because they thought it was safer.  It isn’t.  Chewing tobacco also contains a lot of carcinogens and toxins, and has been linked to many types of mouth and throat cancers.  It is not less dangerous than smoking—it only shifts the cancer site upward.  And it can actually be more gruesome, especially when the surgeons have to remove the whole jaw in order to save the patient’s life.  However, it is a life confined to silence and drinking every meal.

But there are many methods, tools, support groups, and medications available to help you in your attempt to quit.  Only you and your PCP can determine which tobacco cessation program will work best for you.  I just pray that you try, and if you have not been successful yet, please continue.  You will be, and it will be the best gift you can give yourself and your loved ones—the gift of life and health.

I wanted to introduce the power, premise, and promise behind preventive medicine.  And with these several (relatively) straightforward changes, you and I can go a long way to living healthier lifestyles.  But I have only given a couple examples of steps we can take to improve our overall health.  There are many, many more:  avoiding drinking alcohol in excess, making sure that eat enough dietary fiber, routine cancer screening and monitoring, with colonoscopy, mammograms, breast and testicular self-exams, and so on.  But the most important step is the first one.  Please start taking care of yourself.  Our personal health is very important, and by taking a few simple steps, we can all hopefully enjoy many more wonderful years in the country.  Oh, and by the way, I was able to avoid temptation (this time), and I didn’t get a chocolate dessert earlier (one of my many weaknesses), if anyone was worried.

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But there are other conditions that present us with warning signs – red flags that herald the beginning of something much worse.  If interpreted and acted on promptly and properly, heeding these symptoms can help to prevent disaster.  I have seen the results of both circumstances, where families have been spared by rapid medical evaluation and intervention, and other instances where an individual and their loved ones were not as lucky.  With these situations in mind, I would like to share a list of several symptoms that should never be dismissed as “just growing old,” or “it’ll pass,” but should warrant at least a visit to a primary care provider, or an emergency room, for further investigation.

Learn the Symptoms of Potential Medical Emergencies

But, first, a disclaimer.  This information is for educational purposes.  I am giving you general medical symptoms and classical cases for your understanding.  This is not for diagnosis, and certainly not for treatment.  If you are suffering, or even if you are fearful that you are experiencing, any of these conditions, you MUST SEEK PROMPT MEDICAL ATTENTION.  I want to impress on you the severity of some of these signs, and educate you as to some of the conditions that they might represent.  It is up to you, and you alone, to act on that information in your particular circumstance.  After reading about some of the diseases associated with these symptoms, I hope that you will at least call a medical professional to explain your symptoms and get more information and instructions.  If any doubt enters your mind, and you are worried about you or your loved one’s health and well-being, please, please, please go to an emergency room for evaluation and care.  In life, and especially in medicine, it is always better to be safe than sorry.

Now, back to the topic at hand.  There are myriad chest pain complaints and even more causes.  There are also a lot of important organs residing in the vicinity – the heart, lungs, diaphragm, stomach (yup, just beneath and to the left of the lower rib margin), esophagus (the connection between your mouth and stomach), trachea (connecting your upper airway to the lungs), aorta (the main blood vessel off the heart that delivers blood to the rest of the body), not to mention nerves, bones, muscles, lymph nodes, and skin.  All of these organ systems can be involved in chest pain in some way.  Some are benign, like gastroesophageal reflux, or heartburn (which should still be managed with the help of a doctor, because longstanding heartburn can predispose an individual to esophageal cancer), or a strained muscle from heavy lifting (signs of this are that the pain started right after lifting, is a sharp, muscle strain-like pain, is localized to one specific spot, can be reproduced by pressing on the area, and is relieved by ice, hot packs, or medicines like ibuprofen).

What Does Chest Pain Mean?

But there are other types of chest pain that are not as easily explained, and may signal a potential problem.  Chest pain that can be described as pressure or crushing, right under the sternum (breastbone, in the middle of the chest), and may radiate to the left arm or up the left side of the neck, is very concerning for a heart-related condition.  Classically, a doctor that hears that constellation of symptoms presumes you are having a heart attack until it can be proven otherwise.  And, if that kind of chest pain is also associated with nausea (feeling sick to your stomach), vomiting, or profuse sweating, get to a hospital!  DO NOT try to work through it, or hope it goes away, or pop two pain pills and go to bed.  A classic medical saying in these settings is “time lost is heart muscle lost.”

Besides the ultimate adverse outcome (death), the main concern in treating heart attacks quickly is avoiding weakened heart muscle.  The more time you take to get to the hospital, the more you lose of the heart’s pumping function, which makes the heart weaker.  Your heart pumps 60-100 times per minute, every minute you are alive, to deliver blood containing oxygen and nutrients to every cell in your body.  The pain associated with a heart attack is caused by the death of heart muscle cells.  The body does not replace heart muscle with new muscle cells – the area is scarred over and does not contract with the rest of your heart.  This can lead to an insidious and debilitating condition known as congestive heart failure (CHF), which essentially means that your heart has trouble pumping effectively enough to meet your body’s metabolic demands (for oxygen and nutrients).  People who suffer from this condition feel weak, short of breath, tired, and have trouble with swelling, especially in their legs.

The best step you can take when you have pain that could be the presenting sign of a heart attack is to call 911.  I would also have a bottle of aspirin available in your house, and maybe in your car.  Tell the operator exactly what you are feeling – tired, sick to your stomach, dizzy, lightheaded, about to pass out, sweaty, having trouble breathing, numbness or pain in your arms or legs – in addition to the quality (sharp, dull, pressure, crushing), location, and if there is any radiation of your pain.  Tell him or her when it started, what you were doing when it started (for example, exercising or doing chores versus sitting in a chair, or if you awoke from sleep with the pain).  It is also very important to tell the operator any medical conditions that you are being treated for and the medications that you are on, as well as any allergies to medicines or foods.   If the operator thinks you might be having a heart attack, and there are no contraindications, he or she should tell you to take three or four baby aspirin (81mg) and chew them.  If it is at all possible, DO NOT just swallow the aspirin, as chewing them will increase the speed that the medicine will enter your bloodstream.  However, if you have any contraindication to taking aspirin (including an allergy), avoid it until you get to the hospital for medical treatment with a trained physician.  Once you have done what you can, wait for help to arrive, and tell the EMS and the doctors exactly what you are feeling, when you are feeling it.

There is another type of chest pain that the much rarer than the crushing-type pain of a heart attack.  But I want to mention it, because it is much more frightening, and knowing about it and acting quickly could help save your life.  This type of chest pain is a sudden, sharp, boring chest pain that starts right under the sternum and feels like it comes out of your back right between your shoulder blades, or may be under your left shoulder blade.  People again describe having difficulty breathing, as well as feeling very sweaty and cool, that their heart is racing, and some notice that their left arm is numb and cool.

The constellation of symptoms above, especially in the setting of trauma, like a car accident or sudden deceleration (but it can also happen with very high blood pressure, and rarely spontaneously), is very concerning for a condition known as aortic dissection.  In this disease, there is a tear in the wall of the aorta, the main blood vessel of the body.  Blood, under pressure from the pumping action of the heart, can enter and further damage the wall lining.  If the wall of the aorta ruptures, blood quickly leaves the veins and arteries, enters the chest, and the poor individual dies from massive blood loss (exsanguination).

The only course of action for someone suffering from this condition is to get to a hospital immediately.  While there are several courses of action after diagnosis (mainly surgery versus strict blood pressure control), this is only after being stabilized and monitored closely.  This is a very serious condition, and must be treated quickly for the possibility of a good outcome.

Another type of chest pain that should prompt a call to a medical professional is one associated with breathing difficulties.  The combination of these two symptoms means that there is something definitely wrong in the chest that needs to be addressed.  Three of the most concerning pulmonary conditions that present with chest pain and shortness of breath are pulmonary embolism (or PE), pneumothorax, and pneumonia.  All of these conditions can present in a similar fashion, but it is usually the time frame and the severity of the pain and shortness of breath that differentiates them clinically.  When describing the quality of the pain, many people state that it is a sharp, stabbing pain that occurs when they take a deep breath.  The location of the pain is another sign that can help differentiate these illnesses from heart disease.  While cardiac, or heart, problems, are generally localized to the left side of the chest, pain from pulmonary sources occurs when the lining of the lungs (the pleura) is inflamed and irritated.  Another quality of the pain that can sometimes separate pulmonary from cardiac conditions is that movement can make it worse.  But, like everything in medicine, this isn’t always the case.

Pulmonary embolism (PE) is a condition where a blood clot enters the lung vasculature and causes some of the lung tissue to die.  The pain, like that felt in a heart attack, is a result of dying tissue.  The amount of pain, the severity of the shortness of breath, and the overall outcome for the individual are all determined by the size of the clot and how much lung tissue is affected.  There are certain conditions, habits, and events that predispose someone to developing PE.  Factors that can be changed or avoided include smoking (never do it, because it is essentially poison to blood vessels!), and stopping to walk during long car drives and airplane flights (to avoid blood clots developing in the legs due to sluggish blood flow and stasis, then breaking off and traveling to the lungs).  This also occurs when someone is bed bound or immobile for long periods of time, like after breaking a leg and having it casted.  In these situations, you may have to take a blood thinner or receive physical therapy, in order to make sure you are moving enough.  If you suffer from any of these predisposing conditions, and you start to feel the symptoms described, call 911 immediately.  And even if you don’t, you should still be evaluated.  You need to go to a hospital and have imaging of your chest done to help diagnose the condition.  If you are diagnosed as having a PE, you will most likely need to be hospitalized and started on a blood thinning medication.  Pulmonary embolism is an emergency and very dangerous, so you need to treat these warning signs seriously and quickly.

Pneumothorax is a much rarer condition that presents with similar symptoms to PE.  The main symptomatic differences of pneumothorax from PE are the suddenness and the circumstances under which it occurs.  A pneumothorax essentially means that air (pneumo) is trapped outside of the lung, but still in the chest (thorax), and is caused when there is a hole somewhere in the lung itself, letting air escape.  The seriousness arises because the chest is a closed container, with air becoming trapped between the outside of the lung and the chest cavity.  With each breath, more and more air leaks through the hole, causing the lung to collapse and the contents of the chest to be pushed away from the affected side.  A pneumothorax is classically associated with trauma to the chest – for example, a gunshot or stab wound, or a fractured rib puncturing the lung.  But it can also happen spontaneously in people who suffer from lung disease like emphysema or COPD (because there are balloon-like weaknesses in the tissue known as blebs that can rupture), or very tall, thin people who smoke (for unknown reasons).  This condition is an emergency, and is one of the reasons why any person who has difficulty breathing needs to get to the hospital immediately for diagnosis and treatment, which is usually to insert a tube into the chest cavity to allow the air to escape and the hole in the lung to heal.

The last condition I would like to discuss – pneumonia – usually does not present as quickly as the other two conditions.  It is an infection of the lung tissue by a virus or bacteria that causes shortness of breath, and, if it touches the pleura, can cause inflammation and chest pain.  Most cases present relatively slowly, over several days to a week, and are include contact with other sick individuals, fatigue, fever, cough (with or without green or bloody sputum), nausea, sometimes vomiting.  But sudden chest pain with shortness of breath, in the setting of fever, can represent a very virulent and nasty form of pneumonia.  It is not something you want to (and most of the time, cannot) “ride out at home.”  This is a medical emergency that needs powerful antibiotics, special monitoring, and, potentially, the thought of temporary intubation in the setting of extreme weakness and illness.  Treatment is aimed at avoiding becoming septic (having the bacterial infection enter your bloodstream and infect your whole body simultaneously) and dying.

Now, just a couple of words in closing.  The conditions I have listed above are rare emergencies, true, but they do happen.  I want to provide you with the knowledge and understanding to help if, God forbid, you find yourself or a loved one suffering from a heart attack or some other emergency.  Learning to observe and recognize some of the symptoms listed above, as well as what they might mean and what you need to do if you find yourself in that situation, like learning to interpret and plan according to the signs of the seasons, can go a long way in helping to avoid or survive a serious medical condition.

Symptoms of Potential Medical Emergencies, Part Two: Weakness

Where There Is No Doctor: A Manual for All Reasons

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In this article, I would like to discuss several more techniques and lessons you should understand if you find yourself in the hospital setting.  Perhaps the most important thought that I can impress on you is that the hospital is really not the ideal place for sick people.  And yes, I am serious in that statement.  Granted, individuals who are critically ill and injured do need emergent medical treatment, and specialized procedures and powerful medicines in order to save their lives.  But after the patient is stabilized and is no longer in mortal danger, the hospital becomes a dangerous place to convalesce.  A good physician will have a discharge plan in mind as soon as a patient is admitted to the hospital – not because he or she does not want to treat the patient, or is lazy, but to get the patient the appropriate care, whether it is therapy, or continued monitoring, or visiting nursing assistance in the home setting, outside of the hospital.

But that is what common sense would dictate should happen.  And some doctors are not as conscientious of the “big picture,” in terms of the patient’s hospital course.  Common sense in the medical establishment is not quite at the extinction level of the dodo, but it is critically endangered (I guess kind of like Przewalski’s horse, or some other specie where there are only a couple hundred left in the wild).  Mr. S expressed it very well: “I’ve seen big rocks with more sense, and greater ability to listen.”  You can only rely on yourself.  Unfortunately, common sense has largely been replaced by treatment algorithms for specific symptoms (i.e., if the patient has pain, medicate it until it goes away, then search for a now masked cause), and conversations between the patient and physician usually entail ten or fifteen minutes at the bedside asking about pain, bowel and bladder function, eating and appetite, and if the patient can get out of bed or perhaps walk to the bathroom.

Two commentary posts raise interesting points, originally mentioned by Lunamother and echoed by Dancingbear – namely in response to Mr. S’s sentiment that he should have noticed the changes in Ms. S sooner.  They reply that it “WASN’T MY JOB TO LOOK FOR THAT STUFF [emphasis in original text].”  I completely agree that it is the responsibility of the hospital staff to make sound medical judgments using all of the data and information available to them (and if there is not enough available, to obtain it).  This example shows what happens when that is NOT (my emphasis) the case.  I also agree, however, with Expatriate’s quote earlier about being an advocate for your loved one in the hospital.  In the business of medicine now, the hospital is looked at by the CEOs and HMOs as a money-making entity, with hospital beds a prime commodity.  The trick for increased profits is in patient turn-over – the faster Patient A recovers and goes home, the sooner Patient B can be admitted, worked up, and treated, generating a larger hospital bill.

Now, I am not saying that every individual in the hospital is an inept, money-hungry vulture who looks at patients as disease-ridden bank accounts.  Some of us actually did believe the hype, when we first started out, that we were going to help people who were sick and alleviate suffering.  But modern healthcare is not like those Norman Rockwell paintings of the doctor’s office, or Little House on the Prairie where Doc Smith rides to your homestead in his one-horse carriage.  There are still good people, and I work with a lot of them every single day.  But, like everything else in our modern society, there is the rush for results, the I-want-it-now attitude analogous to a fast-food restaurant (and we all know how well some of their resultant products can be), the consolidation of hospitals and resources, resulting in more patients being covered by less staff.  And let’s face it, physicians and nurses are human, and therefore fallible.  That is why there is a healthcare team that rounds on every patient.  The more eyes looking at a problem (be it a disease, a symptom, a riddle, whatever), and the more heads reasoning through it, the better chance something will not be missed, and a successful outcome will be obtained.

But the system is not full-proof.  That is where the patient and loved ones come in.  We are, like Mr. S for Ms. S, or my grandmother for my grandfather, or my parents for me, the first and last line of defense.  It is OUR body, OUR health, OUR life.  We may not know all of the medical language, or how to read all the tests, or whatever.  That is NOT an excuse to follow blindly.  Especially today, in the digital age, where symptoms and diagnoses are as close as our computer, the answers at our fingertips through sites like Google or WebMD.  We know what our baseline is, we know how we should feel and act.  This is true for a loved one as well – if they are not acting properly, but cannot say something, then we must ask questions and demand answers.  If something does not seem right, in terms of new or worsening symptoms, or unnecessary testing, or a treatment that does not make sense, or does not help, you need to ask why.  Why is it being ordered?  By whom?  What is going to be learned?  If it does not work, what else can be done?  Again, you may not have all the answers, but we are all blessed with our common sense and gut instincts.  And if your medical team –  whether it is the nurses, or physician’s assistant, or doctor – is skirting questions, giving you half-answers that really do not resolve anything, or refusing to see you or answer questions outright, make noise.  Demand to talk to someone else.  Get in touch with the nurse manager, or the hospital’s patient advocate.  There are resources and avenues available for you.  Just DO NOT be quiet and sit around while you are uneasy about your own or your loved one’s medical care!

I am happy to report that Ms. S’s symptoms did improve, with the appropriate care and off the offending medicines.  But she was not discharged from the hospital until almost three weeks after her initial transfer.  There was one final response post on the topic of several herbal remedies, such as Daily Detox (which I quickly tried to look up on-line for an ingredient list, but I did not find one off-hand), dandelion tea and milk thistle treatment at discharge to “help cleanse toxins and metabolites.”  Please let me offer one final suggestion/warning.  Know what you are taking into your body, whether it is prescription medications, food, drink, over-the-counter substances, or herbal remedies.  While marketed as “all-natural,” botanical therapies and related phytochemistry have the potential to be extremely potent and have unexpected interactions and side effects.  I am not saying to avoid using these compounds (one has only to remember that acetylsalicylic acid, or aspirin, is derived from willow bark, and taxol, a potent chemotherapeutic agent, from the bark of the Pacific yew tree), but alert your healthcare provider what you are on, so that they have this information when prescribing other medications.  For example, people who take St. John’s wort need to be very cautious about taking aspirin, since the active compounds in both thin the blood and can synergistically increase the risk of bleeding.

Now, please indulge me a few final thoughts in closing out this series.  First, even before you enter the hospital, make a list of all of your medications, with dosages, times that you take them, and for what condition.  Right now would be an ideal time – seriously, it could save your life.  Include any allergies to medications, as well as foods like shellfish, or substances like CT contrast dye (also known as IVP dye).  On the reverse side of that piece of paper, write down all of the medical conditions you are being treated for, such as diabetes, heart disease, stroke, atrial fibrillation (an abnormal heart rhythm), kidney or liver disease, etc., as well as the name of the doctor and specialty that treat each condition.  It is also very important to list all of your surgeries, when they happened, what side (if appropriate), where, the name of the surgeon (if you remember), and if there were any complications.  Make several copies, then place one in your wallet or purse, give another to your spouse, parent, or healthcare proxy (HCP, or someone who understands your wishes, and will make medical decisions for you in the event you are incapacitated), and your primary healthcare provider.  Keep the other copies in a secure filing system or fireproof box for emergencies.  You will need to present this information (or instruct your loved one or HCP) to any emergency room physician or doctor who sees you and is actively managing your care in the hospital.

Once in the hospital, evaluate every physician and nurse, and ask them about everything that they are doing.  If you are going in for surgery, discuss why it is necessary, how it is expected to help, what are potential alternatives, as well as all of the possible risks and complications.  But also realize that all of the statistics and percentages that are quoted are for specific populations, which may or may not accurately represent your particular situation – you are one individual, and the odds of something happening to you, whether positive or negative, will eventually work out to either 0 or 100%.  If, after all of this information, discussion and thought, you decide to go ahead with the surgery, write on the site with indelible marker the night before, AND mark everything else (the other limbs, the other side of the abdomen, etc.) as DO NOT CUT HERE, or something to that effect.  As an example from my particular instance, I heard afterward that the orthopedic surgeon who saw me initially for my knee problem had accidentally amputated the wrong leg on another patient.  Take every means to protect yourself, and do not be that patient.

It might seem paradoxical, but I do not like doctors, I do not trust doctors, I do not want to see doctors, especially after working in the medical field.  They are, unfortunately, a necessary evil in this fallen world.  Learn to take care of yourself and try to avoid the hospital at all costs.  I agree with the comment in the forum, “If you’re not [f*cked] up when you get here, you certainly will be when you leave.”  A hospital is full of sick people, and is certainly not an ideal setting for convalescence, especially in a weakened state.  Infections, medication interactions, and medical errors occur in hospitals.  But amazing treatments and recoveries are also possible, and lives are saved and changed.  I trained as a doctor to learn what to look for in order to maintain health in myself and my family (as well as my pets, oddly enough), to avoid illness whenever possible, and to be a better listener and caregiver than my original orthopedist.  I wanted the wisdom to recognize conditions that were benign versus those that required urgent care and intervention.  I hope to share more of this knowledge in future articles.  The information I have presented here – in the setting of a case study where a concerned husband champions the proper medical treatment for his ill wife – I hope that you will find useful and will serve you, if you or a relative, unfortunately, do have to enter a hospital.

The post Entering the Hospital: Some Facts to Know to Protect Yourself (Part III) appeared first on Homestead.org.

We return to the story now, at another very important point in the clinical course.  Mr. S. commented on December 1 that he was concerned about his wife receiving the pain medication Dilaudid (hydromorphone – a very potent narcotic used for pain relief for kidney stones and cancer, and after surgery, for example), stating that it was “having a detrimental effect.”  At this point, Ms. S. had been transferred out of the ICU for a second time.  Apparently, there was initial concern among the medical staff that Ms. S. was withdrawing from another medication.  But Mr. S. describes, fairly accurately and with an impressive chronology at least suggesting causality, the effects of Dilaudid on her behavior.  For example, on December 1, Mr. S. entered “… she was awake, alert, fairly calm and quite coherent.  She asked the nurse for pain meds, they gave her dilaudi[d] [through her PICC line, a more permanent form of intravenous access], and within about 15 minutes she was having spasms, going delirious, and was incomprehensible in speech.”  He goes on to describe in another post that day that Ms. S. also had hallucinations after receiving Dilaudid.  And, more importantly, he recounts that she “never had trouble controlling pain during previous operations using hydrocodone [another less potent narcotic]; didn’t use it very much either, and it never was a cause of this sort of behavior. That was due to other poorly chosen drugs, which were life-threatening, such as tramadol [a partial opiate used for pain relief] combined with Flex[e]ril [a muscle relaxant notorious for causing drowsiness].”  At this point, he “… suspect[ed] that the effects of the Dilaudid were mistaken for something else” and suggested to the general audience that he was going to request holding the medication, and monitor Ms. S. to see if her symptoms persisted (which would happen if she was withdrawing).  He also postulated using another pain medication (hydrocodone) as an alternative to Dilaudid, since it had worked so well in the past.  Several members in the blog forum respond with posts recounting their own negative experiences with Dilaudid, and encouraged Mr. S. to request that the Dilaudid be discontinued.

I would like to include one of my own opiate “horror” story at this point.  My grandfather has had several major hospital stays in his life.  He has suffered several heart attacks, a broken back after falling off a roof, and esophageal and gallbladder surgeries.  My grandmother often recounts a time after his fall when he was recovering, and was prescribed narcotic pain relievers in the hospital.  She came to visit him in his hospital room, and he did not know who she was, even though they had been married more than thirty years at that time, or even that he was in the hospital.  My grandfather never took any medicines unless it was absolutely necessary, and even then he would begrudgingly take one or two ibuprofen for his muscle aches, but very rarely.  Needless to say, he was completely naïve to the narcotic medication he was receiving.  She asked the doctors at that point to stop prescribing the medicine, and perhaps try something less potent.  My grandfather received acetaminophen (Tylenol), and was still sore, but not nearly in as much pain as he would have been not having any medication.  He was also lucid enough to get up, take care of himself, use the lavatory, and was discharged several days afterward.

To my grandmother’s surprise, she received a phone call from one of the nurses at the hospital a couple of weeks after my grandfather was discharged.  The nurse stated that she had taken care of my grandfather during his hospital stay, and that he had promised her a calf in exchange for her giving him his narcotic pain medicine (this was before it was discontinued)!  Naturally, my grandmother had a few choice words for her, hung up, and never heard from the nurse again.  But I recount this story because it shows how potent these medications are, how careful you have to be in taking them, and some of the effects it can have on reasoning and judgment, even in strong-willed, healthy, responsible individuals.  Narcotic medications, like everything else in medicine and life, are a tool.  They have a defined role, a specific patient population that they are designed to help, and can be of great benefit and offer immense relief – when they are used PROPERLY and after knowing the SIDE EFFECTS and CONTRAINDICATIONS.

Mr. S, like my grandmother, agreed about discontinuing the medications and informed us that he had had a conference with the doctors to discuss the matter.  He goes on to note in a blog December 2 that his requests were accepted, and that the medical staff discontinued Ms.S.’s Dilaudid and lorazepam (or Ativan, a powerful sedative medicine in the same class as Xanax and Klonopin, which can be used as an inducing agent in anesthesia, to help treat alcohol withdrawal symptoms, and is used to stop seizures by quieting neurons in the brain).  Mr. S. then goes on to share on December 3 that he was formally a psychiatric aide, and was trained to observe symptoms of addiction and withdrawal.  He states that he was “soliciting opinions” at the beginning of his entry, then lists a pertinent side effect profile for Dilaudid, which includes significant neurologic manifestations.  After this, he presents a very informative synopsis for the recent admission from November 24 to December 3, recounting his concerns for the hospital course, especially her transfer back down to the ICU for “withdrawal symptoms,” as well as his requests to nursing staff that she be taken off both the Dilaudid and Ativan (which was started to treat the aforementioned “withdrawal symptoms”).

I actually learned the most about Ms. S’s hospital stay from this summary.  It was very insightful.  I hope that he presented this information to the physicians during their conference as clearly as he did here.  At this point, as will become evident shortly, I feel that it is important to note also that I am trained as a neurologist.  As such, I am usually consulted by other services in the hospital (especially surgical services) for patients who are experiencing “altered mental status” or AMS (whatever that means, but that is my own pet peeve).  Causes for AMS are vast, as you might imagine, and range from the relatively mundane (poor sleep in the elderly causing delirium) to the devastating (end-stage organ damage like liver or kidney causing metabolic derangements that are irreversible, or a catastrophic global stroke leaving someone in a persistent vegetative state).    In my experiences so far, nine out of ten cases of AMS are one of three things:  delirium in an elderly, weakened individual caused by pain, poor sleep-wake cycle (which, in the hospital, is constant), and unfamiliar surroundings;  infection (urinary tract infection, pneumonia, bacteremia or early sepsis);  or medications.  My recommendations, besides imaging of the brain to rule out more worrisome (but less likely) conditions, is to promote adequate sleep hygiene (enough sleep, at the right time), orient the patient to the fact that he or she is in the hospital, check for infections with treatment as necessary, and STOP OR REDUCE (as much as possible) NARCOTICS AND SEDATING MEDICATIONS.  In addition to these medicines, patients – especially elderly individuals, should avoid antihistamines and anticholinergics, such as Benadryl, for example, which are sometimes used as sleep aids, because they can have a paradoxical effect causing agitation and confusion (due to the relative balance of the neurotransmitters acetylcholine and dopamine in the brain, and the effect these medications have on this balance).  There is actually an example of this in the blog forum from December 3, recounted anecdotally.

Mr. S. was absolutely right in his observations, concerns, questions, research, and approach to the matter.  I just wish that it had not taken so long for the symptoms to be attributed to the appropriate source and corrected.  Several of the responses to the December 3 post recount similar ordeals, where people had to fight for hospitalized loved ones who were getting inappropriate treatment.  There is one in particular, from December 4, which tells how a daughter had to fight to get medical staff to order a brain MRI for her father, who was being treated for alcohol withdrawal with lorazepam, and was subsequently found to have an intracranial hemorrhage.  And there is another post that accurately describes some physicians’ mentality about polypharmacy – adding additional medications to treat the side effects of the first, inappropriate drug.  As a brief aside, there was a jest (I hope) about giving away some unused prescription medications (in this case, Flexeril, a power, potentially sedating muscle relaxant).  Please do not take medications that are not prescribed for you.  As this blog forum shows us, improper use of medications can have grave consequences.  Medications are powerful tools, or dangerous weapons, depending on the hands and thought used to wield them.

And in Ms. S’s case, the inappropriate medications did lead to a further complication – difficulty breathing due to a fluid build-up.  It was originally attributed to the ativan, which does have decreased respiratory drive as a side effect.  However, when her breathing did not improve after the medication was discontinued, proper imaging and diagnostic testing were done to show “… a pool of fluids [that had] been building in her abdomen, causing breathing difficulty.”  It is unclear from the posts what the source of the fluid was – whether drainage from the surgery (serous fluid, resulting from leakage from injured blood vessels, like the yellowish fluid that weeps out of a cut after the blood), or blood from the initial surgery and post-op bleeding.  The doctors placed a catheter into Ms. S’s belly to drain the collection and keep it from recurring.

As a result of the missed diagnosis, though, she required assistance with ventilation.  I am not sure if it was actual intubation (the tube down the mouth and into the trachea to aerate the lungs) or masked ventilation (like BiPAP, for example, which is a mask hooked to a machine that helps facilitate taking breaths, and is used by people with sleep apnea at night).  Based on Mr. S’s observations (which I have not had cause to question yet), however, since she appeared to be responding to Mr. S. and was conscious that he was there with her, I have difficulty picturing her being fully intubated without sedation, since the tube irritates the throat A LOT, causes people to gag, and patients usually have to be restrained or completely knocked out if they require it to breathe so they do not self-extubate (i.e., yank the tube out and cause even MORE irritation and potential damage).

There is a lot of concern in his posts, and several other responses again offer encouragement by sharing episodes where loved ones required assistance with breathing, all of which were temporary.  A subsequent post informed us that Ms. S. was suffering from pneumonia as well.  Her body was having difficulty with all of the insults – the residual medications in her system, the fluid collections affecting her breathing, pneumonia (which was probably another cause of her breathing difficulty, since an earlier post also mentioned that she was only on antibiotics at that time), and liver and kidney dysfunction.  The liver and kidney are very important in filtering out medications and toxins, both natural and artificial, from the bloodstream.  When either of these organs is not functioning properly, toxins and medicines can build up in the body, and cause confusion and encephalopathy.
There one thing that I did not mention earlier, but, while initially viewed as a “duh,” common sense sort of statement, and it is glossed over by many patients and physicians alike.  Pain is how your body tells you that something is wrong with it.  I know, earth-shattering, right?  But bear with me – I am going somewhere with this thought.  You get up in the morning and have your typical breakfast, and then you notice that there is pain when you chew.  What do you do?  Do you say, “Oh, I have a pain,” then go about your day?  Well, some of us do, if the pain is transient, mild, and perhaps associated with that canker sore on the inside of your cheek where you bit the side of your mouth.  But, in that case, you identified the source of the pain – the canker sore – and diagnosed it as mild and transient, not life-threatening.  What if it was not that simple?  What if the pain arose from a cavity in your left upper molar?  Again, if it was mild, and went away, I imagine most of us would monitor it and tell the dentist at our next appointment (which reminds me…).  But what if it was a big, ugly, bleeding ulcer with pus and junk oozing out of it, at the base of your tongue, and you smoke like a chimney and chew two tins daily for the past thirty years, and you have a mild fever and cough?  Would you take two acetaminophens to relieve the pain and go about your business?  If you are, you would be masking some very important warning signs from your body about the oral cancer that is gestating.  But many patients, their family members, and even nurses and doctors, treat pain, and many other new symptoms, like headache, shortness of breath, and weakness, for example, in the hospital without first doing a work-up to know the source.  Pain is the body’s alarm system – it should be heeded and investigated fully, instead of dismissed and muted.

We have learned several lessons from the Sandpainter blog forum so far.  But I feel that it is very important to point out that the mismanagement of pain symptoms can cause significant complications.  Any new symptom needs to be investigated, in order to rule out a serious medical condition.  It should not be dismissed as mundane and medicated nonchalantly.  The difficulties experienced by Ms. S. after her surgery did not need to happen, but are unfortunately rather common.  Please remember to ask about any new medication – why it is being prescribed and for what symptoms, what is the desired outcome, and how long is it necessary?  And if you have any concerns, or feel that the medication side-effects are outweighing the benefits, request that the medication be stopped, and alternatives suggested.  You and your doctor are a team, and you need to work together for the best outcome in your health.  Your doctor has the medical background and training, and can recommend diagnostic testing and treatments.  But you are the leader in your treatment, and you know whether or not the recommended therapy is working.  You need to let your doctor and medical team know everything that you are feeling, and what you are thinking.  If your healthcare provider is not listening to your concerns, however, you need to fight to make your voice heard.  That is what Mr. S. did in this case.  And that is the most important lesson from this portion of the blog forum.

Read “Entering the Hospital: Some Facts to Know to Protect Yourself (Part III)”

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The lack of communication and listening skills that has permeated the modern medical field was actually one of the initial impetuses that prodded me to become a physician.  At the time, I was about 14 or 15 years old and had hurt my knee during a soccer game.  I went, with my parents, to an orthopedic surgeon for recommendations regarding treatment.  After spending approximately 5 or 6 minutes recounting my story, the surgeon examined my leg, which consisted of rather uncomfortable twisting and yanking motions, but without any explanation of what he was testing for or what the findings were during the exam.  Being a farmer, country boy, and all-around “tough guy” (I only went to the doctor because my knee had an unfortunate habit of popping out at the most inopportune times, like when I was playing basketball, my true passion), I endured it without so much as a grimace.  After this seemingly brief encounter, the surgeon stated that I had a torn ACL (a ligament holding the knee together), that I required surgery, and then proceeded to schedule me for a month later.  I was VERY hesitant to undergo surgery without any imaging first, and both my mother and I asked about obtaining X-rays or some other imaging in order to visualize the supposed damage.  He stated that it was unnecessary, and started to become a little frustrated with our questions.  At that point, my parents decided to obtain a second opinion.  We visited a second orthopedist a couple of weeks later.  After discussing my symptoms, which this doctor seemed to care about, and having a more thorough examination (which, I have to admit, was about as uncomfortable as the first examination – but since he was explaining what he was doing, and what he was looking for with each manipulation, put me at much greater ease), it was decided that I did not require surgery at that point in time (but perhaps later on in the future), and I could do quite well with a knee brace and strengthening exercises.

I hear the same frustration and lack of discussion with the medical staff in the aforementioned blog.  I have reviewed the entire blog, and I would like to summarize the story, interspersed with several points that I hope you will find educational.  The documentation of events begin on Thanksgiving eve, when Ms. S (the patient – these are my abbreviations, and I use them to obscure individual identities, both out of respect for the individuals, and by personal habit and training in regards to presenting cases) was readmitted, and then transferred for higher-level medical care, due to the recurrence of abdominal symptoms.   The symptoms were thought to be related to a hernia (an outpouching of intestine) near a previously reversed ileostomy site (which takes part of the small intestine and externalizes it, usually after significant bowel surgery to remove a portion of the intestines for various reasons, and where gastrointestinal motility is reduced, in order to give the bowel, and patient, time to heal) causing obstruction, and were initially relieved with a nasogastric tube (a plastic tube inserted through the nose into the esophagus and ending in the stomach, which, when hooked up to low-pressure suction, can remove excess gas from the bowels and help treat partial bowel obstructions) and pain medications.

So, in the initial phases after the transfer, it appeared that the situation was under control, and that Ms. S’s condition would be treated quickly.  In the blog entry, Mr. S (the patient’s husband) mentioned that the physicians at the original transferring facility left something to be desired (to put it diplomatically), but that the medical staff, which included the doctor and nurses at the receiving hospital, were courteous, efficient, and proficient.  From Mr. S’s account, he and his wife had been in and out of the hospital several times in the recent past.  His wife had suffered a complication from an errant IV insertion at the transferring hospital in the past (prior to the start of the blog in this forum), which developed a clot and required chronic treatment with a powerful anticoagulant (warfarin).  She also inadvertently received medicines after that experience which worsened her clotting problem and forced her to be readmitted to the hospital, also prior to the start of this blog.  Both Mr. and Ms. S had a lot of reasons to be tired and upset with the medical establishment.  The husband was still optimistic, however, based on conversations with the surgeon at the new hospital, that the procedure to treat the hernia would be without complication and that his wife would be able to leave in “two or three days.”

The initial presentation seems rather straightforward.  To my physician’s mind, I would like to know a little more about Ms. S – her age, the symptoms that brought her back to the hospital for evaluation (I am presuming partial small bowel obstruction in the setting of relatively recent abdominal surgery and a hernia, which would entail stomach pain, nausea, with or without vomiting, and a bloated sensation), the events surrounding the previous hospitalization, including the need for an ileostomy (a major surgery), the clotting disorder which required warfarin, what medications she was treated with, and the ones that she was on when she was transferred to the new hospital, as well as any reactions to medications, now or in the past.  A special concern in this particular case is the mention of warfarin – which tends to induce bleeding – especially in light of the fact that she was being evaluated for surgery.

Now, I would like to present an analogy at this initial phase, to help understand a little more of my questioning, and to demonstrate the importance of asking questions and learning more about hospital care.  I have been thinking about this analogy for a couple of months now, and when I read through this case, it kept coming back to me.  Please bear with my description.  My wife and I recently changed the tires on her car, before winter arrived.  It was the responsible thing to do, and we knew that it needed to be done, but I was not as familiar with her car as I should have been.  It is one of those foreign sport edition models, with the skinny aluminum wheels, and specialized tires.  It had also been in a front-end collision, which required some major restorative work.

Needless to say, I went into the ordeal woefully unprepared and uninformed.  The tires were expensive, to be sure, but the surprise came when the mechanic came back and said that the wheels were misaligned and that one of them had a dent in it.  We decided to have the wheels realigned, but left the dented rim for another day.  When we drove away, the car had a noticeable wobble in the steering wheel, but we wrote it off.  That is, however, until my in-laws rode in the back to church that Sunday – at that point, the wobble became a full-blown shuddering of the back end of the car!  My wife and I took the car back to the garage the following two Saturdays, sitting there, wasting precious hours of our lives, as the mechanics examined our vehicle, found several more bent rims, told us that it was our fault, and that we should not have had the wheels realigned, because the original “misalignment” was probably to offset any damage from the front-end collision.

In the end, the car still wobbles, but it is not noticeable most of the time, and we still have the dented rims.  But there is also the frustration and anger at the garage and the mechanics for not divulging more of this information sooner.  I also feel responsible and frustrated with myself, because I did not do my homework beforehand.  I thought that it was going to be a routine tire change, and that, aside from the several hundred dollars paid and a Saturday wasted, life would go on as planned.

Now, I realize that the medical field and automotive problems are vastly different.  Please do not think that I am drawing a one-to-one correlation between major surgeries or medical illnesses and my stupid poor planning with my Honda Fit.  The stakes are so much higher whenever anyone enters the doors of a hospital, because life and health are at stake.  And, as the old saying goes, if you do not have your health, what do you have?  The thought that struck me on that second and third Saturday, however – as I sat in the waiting room of that garage reading the same magazine from 2006 for the third and fourth time – was that education and preparation would have saved me much of the frustration and heartache that I was experiencing.  Granted, it would not have kept the rims from being bent, but I would have thought twice about realigning the tires, for example.  I also realized that a lot of people do not know as much as they need to about hospitals and all that goes on within them.  It is as foreign to them as the waiting room of that garage was to me.  Knowledge is truly power, especially in the medical field.  Knowing what to expect, and knowing about yourself or your loved one (your body, your medical history, your medications, allergies, surgeries, travel, etc.), even if you do not know all of the fancy jargon, will go a LONG way to help protect you in a foreign setting.

But we will talk about that more in a little while.  Now, let us get back to our case study.  Ms. S had abdominal surgery to remove part of her colon on Thanksgiving morning.  Based on Mr. S’s recounting of his conversation with the surgeon (talk about a third-hand account!), the bowel near the ileostomy site was “gray,” “deteriorating,” and thought to be the cause of the “serious blockage after the former ileostomy.”  Apparently, there were also a lot of intestinal torsions or, as Mr. S describes it, “[Ms. S’s] intestine was tangled up pretty bad, I guess, the doc said it was almost tied in knots.”  One day after the surgery, Ms. S was in the ICU, better but with a high heart rate.  Mr. S hoped that his wife would be able to go home after the weekend (“Sunday, Monday maybe.”)  Subsequent posts by well-wishers stated that “[s]ounds like she’s in good hands” and “…we are so glad that the surgery went well and that [Ms. S] is feeling better as a result.”

She was moved to a non-ICU “floor” bed (suggesting that she required less acute medical care and monitoring) on Sunday, November 28.  Mr. S mentioned that there was a lot of blood that leaked through the abdominal incision site.  She was also still on “pretty potent” pain meds.  It was noted, however, that “[s]he’s definitely better today than on Friday.”  The next day, Mr. S wrote a short blog stating only “Back in ICU.  Won’t go into it right now, but not hospital fault.”  However, as we find out later, there was some concern for possible withdrawal symptoms, potentially alcohol, which prompted Ms. S to be transferred back to the ICU.  There are also questions later on by Mr. S and the blog participants regarding the medical staff and their actions that might have led to Ms. S returning to the ICU.

For right now, however, I do not know how the surgeons presented the procedure to Mr. S, or why he thought that it would only be a weekend excursion.  But, in Ms. S’s case, it was already known that she has had a complicated medical history, previously requiring a major surgery (an ileostomy) and anticoagulation.  She just had a portion of her bowel resected for probable ischemia causing obstruction – a major surgery in itself.  She required intensive care monitoring after the surgery, and was on pain medications to help alleviate her symptoms.  All of these strike me as potential red flags, but not only in retrospect, which I have the luxury of thanks to the blog forum.

Here are a couple of points that may help you in the future if, God forbid, you find yourself or a loved one in a similar circumstance.  Number one, always remember that any surgery is a major medical intervention and should not be taken lightly.  Any condition that requires you to be sedated or fully anesthetized so that something can be corrected or removed from your body is serious.  Especially if you require ICU care after the procedure.  They check vital signs continuously to watch for any subtle change in temperature, heart rate, blood pressure, breathing, urine output (which usually requires a catheter in your bladder), and any other number of invasive monitoring.  It is also a relatively safe guess that someone requiring such continuous monitoring will not usually be discharged from the hospital directly from the ICU, or within several days.

There are exceptions to every rule, but thinking along the lines that the stay will be longer rather than shorter will steel you against erroneous expectations.  Do not expect to get a lot of sleep in the ICU either, or in the hospital in general, which I hear commented on frequently by a lot of patients and their relatives.  I know, it is harsh, and sleep deprivation comes with its own set of problems (trust me, I know, as experienced from both sides of the fence!), but any change in one of these parameters could be the harbinger of something much worse, like internal bleeding, rampant infection or sepsis, heart attack or even stroke.  For example, the fact that Ms. S was bleeding through her incision site could have meant that she was bleeding internally, and it should not have been written off as the result of excess blood from the transfusions.  She needed to be monitored closely, perhaps with serial blood draws to trend her hemoglobin and hematocrit, to see if she was, in fact, becoming anemic from her blood loss.

So, if you have any question about your or a loved one’s condition, PLEASE ASK QUESTIONS, and PLEASE KEEP ASKING QUESTIONS until you get an answer.  I would recommend trying to be as polite as possible (because you get more flies with honey than with vinegar, but I have no idea why you want excess flies—sorry, just a poor bit of humor), but be persistent, and if you feel that your well-being or a loved one is in danger, DEMAND to be heard.  And remember that you are your loved one’s advocate in the hospital when they cannot make their wishes or feelings known.  As Expatriate (a blog forum participant) stated on November 30 (and for which I cannot find a better way to phrase it): “[she] needs you [to] have her back while she’s not at 100%.”  Well said!  Pleasantries have their place, but not when someone’s life is at stake.

Entering the Hospital: Some Facts to Know to Protect Yourself (Part II)

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