Saturday, September 29, 2007

Thin is In

Yesterday as I was finishing my shift, I was about to leave (had to make a meeting for the Medical Reserve Corp of DuPage County and this is going to be an interesting post so watch for it). I saw a chart that was next to be seen by the incoming doc but it was an ankle sprain for which I have a "Saguil Approach" of handling. I decided to take it for the thrill of seeing how fast I could guess the diagnosis and be correct before the tests came back (little game I play while working to keep things interesting-sorry...sounds conceited). Name sounded familiar and by the time I entered the room I figured out where the name was from. As soon as the curtain was drawn, I heard a big...."Dr Saguil!". One of my old patients from the Wheaton office, and her mom and dad were very fond patients of mine. We talked and I gave her an update but apparently her parents already knew I was back in town. Her mom and dad were such great patients. For the non medical person, a great patient is one that has made a lasting impression mostly for some kind of success that was achieved. I can say that the majority of my patients are great. I can usually get a patient to listen or try something I teach in the exam room, (should be called the lecture room since most of my time is spent teaching). To me, if a patient trys something once, then I figure they trusted me and that is a success. I was always a terrible salesman, during college years, I would usually end up giving things away due to some inherent guilt I felt when telling someone about a product I was representing. Anyway, as I found out the exam room gave me a captive audience for 10 minutes (according to medical insurance reimbursement), I decided to groom the way I presented myself when trying to "sell" a healthier lifestyle. Again I refer to the "Saguil Approach" that seems to work for the patients I see. I thought it was just my patient population in DuPage County but during my 18 months in Florida (that just happens to coorelate with a certain restrictive coventant a hospital lays down so as the doc leaving will not to steal all their patients), I applied the same concept and low and behold!....people got healthier and it wasn't just DuPage. May not have worked for everyone...but given another year, I would have had 50% of my population off of at least one of their medicines.
Sorry for the rambling, this one family was always so good about follow up and trying to exercise. The great news and point to this post was mom had lost 40+ pounds since I left! She had a few small short term goals that were easy to achieve and each one "sling-shot" her to the next level of losing.
That day, talk about positive attitude attracting more positive outcomes, I was listening to Paul Zane Pilzner give his ideas about the wellness industry. He's an economist who wrote several best sellers the latest is "The Wellness Revolution", I heard him spout a line that shocked me. He said a few decades ago, poverty was associated with being thin and having nothing, wealth was associated with being fat with alot to eat. Now with 25% (actually 33% with recent stats from the CDC) of america being overweight, the upper crust is thin, exercising and trying to preserve youth at any cost while the middle and lower classes are tipping the scales with a BMI of 30 or greater. (BMI refers to body mass index, read about it on I just gave a talk in Florida and one of the topics was diabetes which is a growing epidemic in the US-mostly due to the high numbers of people falling into the overweight/obese categories. Next time you are at a public function, pick 10 people in one part of the room and look at how many "appear" overweight. It will be 3-4 friends, coworkers and loved ones. Some researchers will tell you the majority of the health issues in the United States are due to nutrition deficiencies. I agree and it is getting worse. Modern medicine is probably not helping due to the amount of training we lack in medical school and residency for nutrition. In addition with the short time we have to spend in the exam room, it is easier to write a perscription and talk of side effects than it is to evaluate and discuss nutrition and diet. And insurance doesn't pay for a dietician unless you have developed diabetes. One of the hardest things I found in private practice was balancing time, I had to see patients that called in with injuries, educate the sick on how to get better and stay healthy, run the office and make sure I was spending time with my family (my cornerstone). I would usually cut out sleeping and eating. Not a healthy way to set an example and one of the reasons I decided to leave the hospital.

Suffice it to say, I am now happy, spending time with my 3 year old, making up time with my 13 year old, and falling in love with my wife again. Not to mention I now fit into my highschool track and field uniform....(if you ever see a black warm up jacket with Eustace Track on the back...that's me!), never thought I would see my six-pack again. I always, always told my patients "a major lifestyle change has to be made or your health will fail"....I even spent extra time doing this to get my point across so hopefully they would see how important it was. That was all at the sacrifice of my own health and until just recently, I didn't even realize I was also a victim of the same poor nutrition, poor rest and lack of exercise. It took a CEO change at the hospital to get me to wake up and it will probalby take a major catastrophy to change the way US healthcare is today but why wait till then. By exercising right, eating right, sleeping better we can inspire others to want to do the same. Living healthy and happy is "infectious", find someone who watches their diet or fits exercise into a busy schedule and hang out with them, you may get "bitten" by the habit. We can all make the world a better place.

Tuesday, September 25, 2007

Hitting the Wall

To continue on the same discussion as last posting, I saw a patient who had been a "frequent flyer" to the ER for pain. Headache, back pain, arthritis she is again and as soon I lift the chart, there's a long list of previous visits and all the narcotics that ended each visit. Taking a few clensing breaths, I entered the "cage". Me versus the evils of narcotic drugs, no holds barred, no referee (aside from the DEA) and hopefully I can stay calm and use my doctor know-how to put a finishing move on this evil and rescue my patient.
She had a headache that was 10 out of 10. Lights were off due to her sensitivity to light, neck was stiff, position was in an embryonic defense. Like one fighter approaching another, chin tucked down, shoulders forward and curled in, arms close in, eyes being hid and forehead wrinked like a chinese shar pei. Husband was sitting in the corner, patiently relaxing but there was a little look of frustration and a kinda "here we go again" face. I interviewed her and drove down all those roads that would pick up stroke, seizure, head trauma but all seemed negative. Physical exam was normal aside from the description above. The MD in me wanted to cut to the chase and see what would happen if I just gave her a shot of something and maybe she would go. The ER was backed up at that time and people were poking their head out into the hall looking for when I would come see them next. I decided to order something "different", an alternative that no one may have tried before just in case she was going to say "it's still a 10". For chronic pain caused by muscle, I have used capsaisin, a pepper derivative formulated in cream that is strong enough to distract the perception of pain and divert the patient to concentrate more on the burning of the pepper. (Science also says it depleats substance P in free nerve endings) After getting to a few other patients, one of the nurses stated she was unchanged and wanted an IV of narcotic medicine. At that point, I went in but noticed she wasn't as curled up as before. Glasses were off and she was laying down in bed. Husband also came out to tell nurses she was looking better. Physical exam revealed a softer trapezius and more supple neck. I asked her to relax her forehead, take some deep breaths and try to pull her shoulders back and unclench the neck muscles. She was able to do so and for that fleeting moment, she looked like a normal grandmother. After explaining the theory of muscle relaxation and the ways narcotic pain killers can actually cause a headache, she started to frown again but I came right back and told her to fix it. I also asked the husband to consider giving her a mirror to carry that would help her with biofeedback. She soon unleashed an emotional cry for all the things she has been through for headache help. She had been to the Diamond Headache Clinic in Chicago, University Hospital in Chicago and thento a Pain Clinic at Mercy Hospital. All the docs had done a million dollar work up and started her on a few pain medicines. While talking she had developed dry mouth and I figured it was from one of the muscle relaxers we give for chronic pain. I tried to keep her on track but she did elaborate all this in about 10-15 minutes. I looked her in the eye and said there is another way of medicine she hasn't tried yet. Two minutes into her monologue, acupuncture immediately came into my head as an alternative. I thought she would make an excellent patient for traditional chinese medicine. I repetitively mentioned an herb shop down the street and the last time I visited there, I found an acupunturist name and number. (This was 2 days ago...funny how positive things happen for a reason.) I told her it would probably take about a year to get good results but even one medicine bottle in the garbage every 2 months would be a success. I explained to her that she has to change her concept of temporary success in the ER from bringing down the level from a 10 to just having a softer muscle or a more mobile neck or being able to take off the glasses. Short term success can keep a patient going till the next goal. This versus telling them get off pain medicine by next month.
The interesting thing about last night was I remember not giving her any further medicine aside from the shot and cream 1-2 hours earlier. I also remember walking her out with her husband carrying her purse (the thing weighed 2-4 pounds). She was also smiling and joking about seeing me outside the hospital intead of inside the ER. If I played the usual treat her and street her, she wold probalby be back to another ER or pain center in a day or two. Don't know if she will follow up with what I suggested (the power that narcotics has for altering lives in a bad way is unimaginable). Put it this way, if she continues on this path, she will probably have a major complication from the list of meds, husband will leave her or she will attempt suicide. Sounds very morose but with no balance in her life and her only savior for 1-3 hours being a strong narcotic pill and the doctors that give her this saying there nothing else that will help her.......what would anyone else do?

Thursday, September 20, 2007

American Nightmare

It was a beautiful day in the western suburbs of Chicago. I got in early to rearrange the doctors office (the feng shui was messing my day up) and the trickle of patients came in gradual. I remember hearing a "stat " overhead page for the emergency response team to assemble ......then the operator said to go the the sidewalk outside the office. A little unusual, but I kept on working. Soon came accross a patient who was complaining of a multiple body part injuries. If there was any space on the sheet for chief complaint, she needed to add about another sheet for everything that hurt her. In the ER, it's common knowledge that if a patient comes in with multiple problems all at the same time, they may be looking for strong narcotics. Now here comes the mentality of todays doctor; in the office where we are supposed to heal the sick as our primary goal in life, it has turned into practicing speed medicine as the primary goal. To pay for the nurse, receptionist, carpeting and all those other fufu things in the office that attracts a good crowd, I am supposed to be efficient with time. It boils down to the insurance companies reimbursing as little as possible for them to be profitable. (Then me seeing and billing as much as possible to stay afloat.) And they take their que from the government who pays the least of all insurance companies to doctors and hospitals -and until recently didnt pay for medicine. (What an irony........we work hard to get to retire but when we get their our health fails from neglecting it for so many years and the insurance we need, pays for the basic minimum.) It wont pay for a dietician for high cholesterol but it pays for a bypass surgery. It wont pay for exercise and physical therapy for obesity but it pays for diabetic insulin pumps. So to make my office and all the bills generated from hiring people to call the insurance companies for approval or paying for the guy thats sole purpose is to copy charts that are submitted for audit by the insurance company, to make sure I make these payments I have to see so many people in a block of time. Forget 9-5.....forget lunch....forget weekends with the family....I must pack as many people into an hour of patient care that I can. To be efficient, other docs have come up with streamlining a treatment plan once the diagnosis is made. That way I am in and out of the room and if a common treatment plan is established, my nurse can go in and discharge the patient. There are some young guns male docs who claim they can see 40-60 patients in an 8 hour day. Just calculate it yourself, thats 5-7.5 people an hour. Thats 10 minutes a patient. I have to get a detailed history, examine, order labs tests and discuss treatment and follow up all in 10 minutes. Well those young guns are sooooo good if its a cold or cough and nothing else is going on but wait....what about the elevated blood pressure in the guy who had a cold. "Oh, its just white coat hypertension" so "watch it". We can wait till an organ shows damage and you get symptoms, then we'll take more time. Or perhaps you can take time off from work and come in 2-3 more times so we can take care of the other 2-3 more ailments. Or get a babysitter so we can get you in to show you on paper that all your tests are normal even if we could have called but malpractice says you have to be scheduled in the office so we can document you received results

Wait....I digress. This lady had the audacity to have more than one body part to complain about in one visit! You guessed it, she was the one who fell outside on the side walk and couldnt get up due to her bone on bone left knee and multiple disc diseased lumbar spine and the fact she is obese and suffering from "fibromyalgia". ( this disease state every muscle is stiff and painful, she gets no sleep and probalby depressed). Well, she was on her way to an orthopedic doctors office since her primary care doc couldnt give her more than 3 months of narcotic medicine and recently cut her down to one month with less pills and no other substitute for complaints. She has public aid and they dont pay for a pain clinic visit. The old orthopedic surgeon wouldnt operate on the left knee until she lost weight but public aid wont pay for a dietician, and physical therapy is also hard to find to accept the card.

Of course after I evaluated her, no fractures to left shoulder, elbow or back. Immobilizer wouldnt fit her knee, she felt little better with sling to the shoulder and a shot of toradol (injectable antiinflammatory) in addition to two darvocets (narcotic analgesic). She was able to stand with crutches and as she attempted to get to the bathroom she held her balance well, (even without the help of her son who was sitting in a chair with a blanket over him....what happened to chivalry?) I am well experienced with sportsmedicine and have multiple patients with fibromyalgia so I started her on a cocktail of morning steroids, evening antidepressant and darvocet......yes I gave a refill on the same drug that her primary care doctor wanted to deny her......but......I also gave her a script for physical therapy specifically to design a core exercise program and work on her gait. Also told her of a local herb shop where she may consider starting valerian and st johns wort in addition to a multivitamin and turmeric. Also told her about how neurotransmitters in the brain get depleated after a few days of stress and then the brain senses everything as painful. Not sure if she can afford everything but at least I was able to give her some options instead of going straight for pain medicine. This is one of those times when a little explanation may help the patient understand her own disease process and help them seek out alternatives since current economic status will not be able to protect her from spiralling downward. Not the American Dream she was envisioning when she was growing up!

Turmeric- is known for its antiinflammatory properties...excellent and is thought to stimulate some of the same pathways as motrin and celebrex without the side effects

St Johns Wort- approved to be used in mild to moderate depression. Mechanism is thought to be settling to the depressed mind due to its serotonin increasing properties.

Valerian- considered a tonic herb. One that works to settle nerve ending, thought due to gaba receptor action like benzodiazepines.

Fish oil would also be great for her with recent studies showing usefulness in depression and heart disease and arthritis/inflammation.
Omega 3 would be choice but it would have to be a balanced fromula between omega 3 and 6.

St Johns Wort and Omega 3 have been the most studied herbal supplements and you will notice I said "thought to work" because FDA doesnt do multimillion dollar studies on "food supplements" (the category herbal medicine falls under). Ther are many good supplement companies out there with excellent results but for every one there are 3 that are not putting the ingredients in the bottle stamped on the label. Bad people will always try to make money to get to their American Dream also, even at the expense of the sick.

Wednesday, September 19, 2007

Looking for the White Elephant

I get in tonight and the place is hopping. My partner that is to leave shift has one person to tell me about that will be staying extra long. 26 year old teacher with ongoing diarrhea for last few weeks. Seen by her primary care doc about a week ago and supposedly no sick contacts at that time. She does work in a primary school and there are sniffles going round but no stomach bugs. She actually did ok with that episode and it cooled down in few days. She remembers that didnt bother her much after that until hubby took her to Olive Garden. Soon after the whole thing started again. Diarrhea, few times a day with mostly water. Last few days it seems it got worse and was associated with nausea and fatigue. Patient admits to alot of issues with "her stomach". No alcohol, only occasional coffee, no tobacco. Mother was in room and she stated she herself has a consitpation issue and patients sister is bad with stomach issues.
Her primary care doc wanted to rule out parasites and C. difficile ( a special bacterial that usually follows antibiotic treatment and leave the patient with bloody stool) He even wanted to check for norwalk virus in addition to the 20 other lab tests he wanted done in the ER. Girl was tired with bags under the eyes, pale, cracked lips and thick saliva on the toungue. Couldnt get up from lying down. Obviously dehydrated with orthostatic changes during standing.

I gave her 2 liters of fluid and a tagamet pill. I had talked to mom about using "slippery elm" and once the gut was a little stronger to consider resupplying the colon with acidophyllus. We started to talk about how the 36 feet of tubing from mouth to anus secreates, digestes and moves. When a small infection occurs....this is one of the only body systems that can protect itself. Just let it do its thing and the toxin, agent, chemical, bacterial or virus will usually be pooped or vomited out in minutes. Even with something as harsh as Salmonella, no need for antibiotics with gut just finds the closest door and pushes everything through it. Well, her gut was probably doing just fine and healing up. No doubt the Olive garden has two things that are bound to have alot of acid....vinegar and tomatoe. (salad dressing and pasta, there goes your whole meal right there.....and dont forget the dairy dessert to follow). I explained when the gut has to move fast to protect itself, that delicate lining of little finger like projections in the small intestine get sloughed off and pooped out. Like an abrasion on a knee, it takes about a week to get things healed. You throw food like that mentioned on a roughened lining and it wont like it....thus the return of the diarrea. Just think of the colon as a separate living thing trying to protect itself from further irritation. Its gonna move just like it did when it started 2 weeks ago. ALthough the initial thing that caused all this to start isnt there anymore, the bowl movements will seem exactly the same. Thus the reason the doc is looking for a white elephant instead of concentrating on the regular elephants that are right in front of him.

After the water she was acutally seen standing up walking to the toilet, not dizzy, red lips, moist tongue and smiling. I told her no need for fancy tests at this point. Need to just go home and stick to fluids over the next 24 hours. Also suggested the slippery elm as stated above. No dairy, No acidic foods, no caffeine. Further evaluation reveals she is a full time teacher, going for a night degree, taking care of her own child, and helping her husband with his line of work. I discussed with her the need to carve out 10-15 minutes a day of medication. Told her to consider ginger root in addition to slippery elm. May consider kavakava or valerian in near future for stress reduction. Told them no need for the fancy tesing esecially if she feels better. Also told them that many times, we in conventional medicine will not know the exact diagnosis but while sick we'll get alot of tests to look for something....anything. Gut doesnt need a fancy name or treatment plan, just needs some healing time before being battered with the next bout of being unhealthy and eating poorly. Girl walked out with mom, smiling and looking forward to visiting the herbal shop in town tommorrow. Mom then preceded to ask me about other "remedies" for her ailments............but that for another day.

Tuesday, September 18, 2007

Why generic isnt always good!

......So I walk into the room and this guy is pale and lying down on the gurnee with a monitor on his finger. He has a little accent and asks if I "habla". My good filipino looks always fool people into thinking I am hispanic. Well, I tell him "poquito"and he proceeds to use the spanish dictionary on me. Comes down to: chest pain for 6 months and now he's fatigued. I get a family history of father with heart attack, he used cocaine snorting it 3 months ago but it was only a "little". No fever, cough, weight loss, chest trauma or nighttime awakening. He is holding his left chest. Pulse rate is slow in the 50's but no sweating, cough or shortness of breath. No ankle swelling.

I get the usual tests and ekg, chest xray are ok. CBC shows little anemia but no infection....."ok, this must be the reason for fatigue but why chest pain?" He denys any bleeding and states he eats ok. More tests come back and looks like his liver is backing up! Hummm....maybe its hepatitis....ordered a hepatitis panel and asked if he used IV drugs or had high risk IV and no sex for 7 months. (OUCH!) Get his thyroid test back and "BINGO"...he's got a slow working thyroid. But why the anemia and chest pain? And for that matter....why the liver back up? Physical exam is all normal exept for the pale skin and big round red marks on his back. [I knew he saw an acupuncturist cause we do cupping to the back]. I ask, what did the acupuncturist give him and he said 3 bottles that he took for 2 weeks but he doesnt know the names. Also, he can't vocalize why he went all the way to downtown for this guy. [Did I say he has a hoarse voice also?]

So we have a 20 year old mexican-american, 6 months of chest pain, fatigue -and all worse in the last few days. Low thyroid, anemia, liver congestion and slow heart rate.
Final test comes back ...... he has full blown "rhabdomyolysis"! This is where the muscles of the body "denature" and start to leak into the blood stream...if gone unchecked the big proteins in the blood will block the kidney from filtering and kidneys shut down. (By the way his kidney test came back and yes he was in stage 2 failure.) Got the family to bring in the meds and here they are, scanned:

Looks like some back door manufacturer of traditional chinese medicine. Called my pharmacy friend, Clell Fowles out of Utah but it was late and still waiting for call back. In the mean time due to the muscle enzymes being the highest I've seen in a few years- (last time was with a patient who did the chicago marathon and got to 26 miles where he saw the finish line but then he woke up in the ICU 3 days later due to severe dehydration and hyperthermia -from not drinking enough during the course, leading to muscle breakdown). Only thing, in this guys case is that the thyroid issue and fatigue are explainable, maybe a little anemia also ......but massive tissue break down with backed up liver. Got to be from the herbs.....not necessarily from the specific component but from the "God only knows where this bottle is from" part. The "vitamin shoppe", "gnc", "walmart", "walgreens" and "target" are real cheap but one in four bottles acutally has the active ingredients it states. If quality control in the US stores is sometimes questionable...imagine a third world country importing their supplements to smaller stores. Work up is under way but I think the guy is out of the woods since he came in "early", (kidneys would have been shot by the morning). In summary he truely had a low thyroid state and anemia but unfortuatelywent to get treatment with acupunture (for that I applaud him) but happened to take herbs from a person that imports straight from the mainland (China) and stuff he took had a side effect. FDA can't regulate supplements so all those bottles really don't have to contain what the label says. Good established companies are always safer. Long standing herbal shops with active in the community herbalists are good. Especially if the company offers to fly distributors out to see where things are packaged. ........Buyer beware, over the counter supplements can kill!

Monday, September 17, 2007

Luke....the force is not with you!

When I was working for Central DuPage Hospital, I really thought I would be making an impact on the families in Chicago's western suburbs. I believe I did, and the heart-felt letters from my patients when I left in '05 proved it. The hospital looked at numbers back then and me, my office partners and many of the other primary care offices were not turning a profit with the amount of patients coming through our doors. No hospital administrator ever showed me a spread sheet for the procedures I sent patients for at the hospital or the therapies I would order to "rehab" my injured. Not to mention over the 10+years I worked for them that every time I proudly stating I was a "Central DuPage Hospital" doctor, patients would trust in the hospital choice I gave them to have their kids or get surgery for their parents or even just tell their neighbors to go to that hospital.
I know my families appreciated me and it's uplifting to hear everyone looking for me even before I open my new office. My committment will be to the community I was taught to serve. The hospitals won't go away, we need them. What I teach my patients about health and wellness won't go away, in fact, I am hoping it gets passed to the next few generations. Those that ran the system and influenced it to be accustomed to wallstreet like mentality.....those people will get older. When you get older and carry a negative disposition and a calloused personality...........well, you get sick. And their lies the irony, I may have to care for the person that destroyed my bond with a good community.........see you soon!

Sunday, September 16, 2007

Reinvented Me

This weekend I went back to Clermont to guest lecture with Clell Fowles, a pharmacist from Utah. We had been invited by The Herb Shoppe to discuss 6 topics. A good mix of ages and sexes attended in addition to at least one other MD. It was a challenge to attempt lecturing to a wide audience with broad topics but the reviews were all positive. Judging from the Q & A after each topic, people were eager to learn and they were following along with me. My only wish is that the medical community could instill this fund of knowledge to each and every one of it's patients. I believe there are some physicians who have a passion for teaching and allowing the injured or sick to learn about the disease they are being labeled with and take hold of it and fight. Once a patient knows how things work with disease and the body, it's not so "foreign" to understand and the plan that I suggested can be faithfully followed without question. Not knowing where the road turns makes a driver slow down and take extra precaution. When a disease takes hold of the body, time is so precious. Just ask some of my cancer survivors or the families of those that didn't.

Dr. Joseph Helms from UCLA taught me there are other ways to care for the sick that have been around for 3000 years. When his technique of placing a chinese needle into my torn rotator cuff, (that I has a sportsmedicine physician with my network of extraordinary physical therapist and my collegues from downtown who put shoulders back together for million dollar baseball player), returned my shoulder back to full painfree range of motion even with an mri documented labral made a believer out of me. This is when I began to accept alternative medicine. I dove further into it with traditional chinese medicine then the teachings of Andrew Weil, MD. Applying the theories these guru's have taught me and working with the herbalists in Florida has improved the quality of life for any patients. I feel it's my calling to bring this positive way of healing to other patients and doctors. The way healthcare is structured in this country is not working, I am on the front line and I come in contact everyday with people who are suffering. I am going to make a change and whether it affects one family or all the families of the United States, I have to do it............God please continue helping me!