Friday, October 26, 2007

Da Bears!

I saw one of the staff of the Chicago Bears Organization today. Funny, I met him a the Naperville Mercedes dealership in the parts department. So this huge guy that reminded me of a professional wrestler, had a 3-4 week problem with his nondominant hand. The guy exercised regularly till the injury and it showed with the size of his deltoid alone. (All during the time I was talking to him, I was thinking to myself, if I had to use and acupunture needle to his shoulder, I would have to order a special long one just to get through that muscle.) Well, it wasn't in his training he was injured but in a 20 second move of a firepit. (Again my mind wandered....was it a firepit or an entire chimmney he moved?) Problem was that since it was a small muscle in the forearm, it prohibited grip, pinch, and wrist rotation. A "dud" left arm ment he couldn't do symmetrical lifts in any of his exercise movements. Not good to be off a lifting program if job performance depends on size whether to use force or just intimidate. (Alas my mind wandered on to think... if I didn't come up with a diagnosis, he could pick me up and throw me to the otherside of the Mercedes dealership!)

I always tell my lecture audiences that 80% of the diagnosis to a problem will be in the history of the ailment. Thus a good reason to seek a doctor that listens and isn't pushed to be out of the room in the "magic 10"-(the 10 minutes it takes to listen, feel and write out a prescription with most of the talking being on the side effects of the medicines being given). Well, same here with this BEAR of a man; the sudden pull, the degree of twist the fist was in while he reproduced the motion he went through while pretend pulling the firepit and the lack of anyother defects in mechanics for this "athlete" pointed me to a common ailment in the elbow. It is acutally a misnomer, you don't have to play tennis to get it. It so happens that tennis players often get this from trying power backhands. The front hand on the racket gets alot of vibratory stress suddenly with impact and the muscles don't like it. Stress leads to microscopic tears in muscle and blood acumuluates to start healing but the forearm can never be truly rested so we continue to tear it in everyday activities. In summary, it's the initial sports shock that usually causes the injury but its everyday actions that keep it going. Here we have a single pull in a very muscular arm (that is used to lifting enough iron to make a little mercedes c class) being used the wrong way. Now that little muscle is shutting down the motion of the entire beefy extremity. He's rested it for 3-4 weeks already so now its time for me to step in.

Here The Saguil Approach is to actually, leave him in the hands of a capable therapist with further suggestions of continuing his multivitamin, taking an antiiflammatory medicine, cross training for now to keep cardio up and substitute the endorphin rush he is used to, adding herbs like turmeric, boswellia, white willow bark to the diet, and stretching the forearm in positions Steven Segal would be pround of. If all else fails, I bring out the acupuncture needles but I may have to order to extra extra long needles from china.

Something for me to stress to those interested, just going which ever physical therapist is covered by insurance isnt an option. In my experience with college level, olympian or just average joe athletes, a therapist can make or brake a musculoskeletal problem. Just like doctors, there are ok therapist and there are great ones. For something easy like an ankle or a knee, standard PT is ok. For something complex like a neck or a shoulder(-my favorite), if the therapist isn't used to measuring scapular slide or can't do manual therapy to a trigger pointed trapezius, the 2-4 weeks in therapy may just result in a failure and it's one step closer to pod cutting, (orthopedic surgery)


Wednesday, October 10, 2007

What really happens in Concussions:

Here's me, Sherrie Payton(Mrs Walter Payton), Gabrielle(my daughter) and Brandon(my son) at the talk.

I was at Healthplex in Aurora giving a talk on concussions. I met a great person that had old fashioned parents. The good kind of parent that was down to earth and followed a proper diet and got to bed on time. She seemed to have very good balancing skills with multitasking and most of all, very good at choosing and sticking to a healthy diet. Seems like her kids respect her and are following her ways of watching what goes on her plate and in her arteries. She unfortunately has some stressors typical for a high profile woman in the millenium but also has plans to deal with the stress. (I wanted to suggest more immunesupport, and antioxidants while in stress in addition to yoga and breathing classes-that defensive postion, in tolerating stress places most humans into a two fist forward, shoulders forward, back flexed chin down postion. This is the usual set up for neck stiffness and pounding headache, chest pain that comes with stress easily fixed with deep breathing and chest opening!)

The reason I bring this chance encounter up is that we are seeing a few of the baby boomers now getting in great shape. Seems like the 50's age group now is getting a taste of health with the advent of 5k's, healthclubs associated with physical therapy, numerous supplement companies, (some of them very good while many others crappy, with poor bioavailability). In the populations I have come in contact with from the Wheaton-ites of Dupage, to the newyorkers transposed to Florida, to the developing cities of Aurora and Oswego Illinois, 50% of all I see are with a BMI of 25(overweight). 40% are normal or close to overweight and 10% are in good shape. Most of the answers for the 10% club say they are doing good because they want to stay off medicines, most of the 50% say they dont know what a BMI is or that they dont have insurance so they havent seen a doc in a "long time". Bottom line is we are a very unhealthy nation leaving our health essentially in the hands of the fast food people hoping these companies and restaurants are doing a good job at declaring "fatfree" or "caffeine free" or "no transfat". Well, guess what, all that great tasting stuff is taken out with the addition of something else synthetic sugar substitutes...places still need to sell and "hook" buyers so they will pay and return to pay again. Doctors have great intentions to watch our risk factors and reverse them once found.....but that is usually it. ONCE risks are found, medicines can be used but you are now taking a pill every day for the rest of your life. It should always be a temporary bandaid while we make changes in life and diet. I have had the worst risk factor laiden patients get off most meds with a major reversal of diet and health habits. It's hard to keep up but once used to the diet schedule, and more over, once you get a taste of "this is how I felt when I was 20 years younger" now that is addicting and it is worth suffering through not eating that crispy cream donut and instead going for a fresh crispy fruit or colorful veggie. As I have said before about the millenium doctor office, time is money and the average visit with all medical algorithms in place only lasts for about 10-15 minutes. Not much time to figure a dietary diary over the last two weeks then come up with changes to work into the weekly grocery list. Again I say that insurance should pay for nutrition visits but seems only covered nowadays is you already are manifesting diabetes or refractory cholesterol control. (I remember once when high blood pressure was used to pay for a visit a dietician).

The "Saguil Approach" would be to find a nutritionist or napropath who knows food and pay out of pocket, visits would be finite, eventually the learning curve will plateau and one should be able to continue on alone. Patient should be able to apply the charges to a health savings account for tax free benefits. On the doctor side, billing for face to face time and counseling is LEGAL but one would have to document topic and time spent. Front desk would also have to be creative in scheduling the up coming patient for counseling dietary habits and using more time than 15 minute slots. (Certainly seems like an extra 15 minutes doesnt amount to much but if 75% of the medical problems need nutrition counsel, 75%of the schedule has to be lengthened and that translates to a 12 hour day of just patient contact. Add on 2 more hours of paper work and 1-2 hours of rounding at a hospital or volunteer work and you have broken the 15 hour work day!..hoooray!) I can only tackle one problem at a time and now it is "intellectual marketing" as Paul Pilzner refers to teaching. If enough people get taught nutrition, enough can write a letter to their insurance companies and maybe an insurance company may change what is allowed for dietary visits. I'm dreaming .....but me and Martin Luther are allowed to.

Friday, October 5, 2007

Turn your head and Look Away

I was told to not write scripts for physical therapy while working as a doctor in the emergency room because therapist will call to discuss cases and we arent built to answer primary care issues with patients we see for one visit in a year. The general idea of and ER is to "treat and street", take care of immediate issues and if not life threatening, send them back to primary care. Problem is that many people who cant afford insurance use the ER for their office doc. Even people with public aid will have ER visits paid for but primary care may be paid for but will be difficult to get into.....thus they also see the ER for primary care. Then there are the well established doctors who have very full schedules and cant pack in patients for same day appointments so send them onto the ER for what "sounds like it needs an ER visit symptom". Since I have been working in the ER I have noted that the average patient may wait 2-4 hours. This is a wait that will range from sore throat to chest pain.

One of the reasons I write is to kinda of gripe about the need for efficiency but the resitance for change. I have training in sports medicine and medical acupuncture more than most of my counterpart family practice breathren. This doesnt win me a bigger paycheck or a higher position in a hospital. Ney, I get paid the same paycheck at everyone else but I may get patients cleared of their disease state faster. More due to the fact that I combine physical medicine with conventional medicine. A regular primary care doc would probably be able to come up with the same diagnosis but an extra step or two is saved due to the fact I dont have to get another consult to help with ongoing care or treatment. (example: if ortho is needed, it will usually take about a week to get one to see a patient and that is after the right test is ordered)...that could translate to a week of lost wages or a week of a mom staying home to care for a kid that could have started physical therapy sooner.

I digress, in the ER I see alot of sprains and strains. I know how to send off and I even write specific plans and orders on the script to physical therapy. The option is always to start it and just have them follow up with primary care if they still need something after a few weeks or if the patient suffers a set back while in PT. So I save the patient, save the primary care docs office the hassel of seeing the patient after the accident or trauma and then prescribing the same script they would have written in less detail, saved the patient time at home doing nothing waiting for a call back from the primary care doc or ortho docs office, saved the work from paying for a temp to come in and do the work of the individual for his or her time off. But ....if it goes off the grain of standard procedure I shouldnt do it. Dont get me wrong, The administrator is doing the right thing by saying to hold it cause the system isnt set up to follow these people I am helping (an I am doing it at a discount since I am not getting paid for giving my expert opinion on the topic of how to care for a specific injury).

To expound on the topic, I have alot of nurse freinds who have been trained to be managers but it is just too much hassel and political red tape that even with training they step down to routine "grunt" work because the excessive frustration isnt worth the extra few dollars on the paycheck. Also a higher liability, since one that is higher on the food chain is also accountable. (more of a scapegoat when needed)

Patients know this and they will pay extra just to be in the care of a doc that knows their particulars. This concept is growing of "concierge medicine" which used to be called boutique medicine since it seemed to cater to those who needed foofoo care and hand holding. Truth now is that patients know faster care and more efficient care can be managed if the doc knows you and is willing to cut corner in caring for you, whether it is in time to see him, time to get to talk to consult or time to get out into a procedure. The catch is a family usually has to pay a "retainer fee" to be in the docs small circle. Doc usually takes 500 patients only to devote more time to each one. (this compared to the 2500-3500 patients needed per year to break even with the expenses of a 1-2 man office) Imagine a family paying an extra 1000 -1500 dollars a year on top of medical insurance bills.

I believe this is also the reason people are shying away from docs and conventional medicine due to the doc doesnt spend time to listen since he or she is so busy that they only spend the bare minimum to hear a select symptom or two and make a great diagnosis to prescribe the standard prescription medicine and have them follow up. Patients are never one medical problem now a days. With all the pressure today and 50-60 hour work weeks, dual income families, poor eating and poor health, even if they only complain about one thing, there are two more to address that have to be postponed until 1-2 weeks when the next opening is available. The proverbial 15 minute slot has to be followed or a practice with go belly up paying for all the extra people needed to take care of the paper chase that the insurance companies create to keep money in check. Well, I do what I am told and dont write scripts for PT anymore....tonight was painful because a patient whom I was treating could have used physical therapy quickly but now I had to send her back to the clinic that couldnt fit her in tonight for a simple sprain. And she will probably spend 3 days getting an appointment, then another 3 days to see a specialist, then another 3 days to get to PT. At least the nursing manager said the idea was good but it has to be approved by all primary care docs before I could do it and the other ER docs had to agree. I'll submit it to the house to be approved by the senate just to be veto'd by the higher ups......oh well! Just do your job and turn away is what my wallet says.....but my heart says help the sick! Where is Hippocrates when you need him!

Tuesday, October 2, 2007


Whats the deal? Tonight I had two patients,one in for an infection and the other with chest pain. Both had difficulty with controlling their individual problems. No other complaints told to the triage nurse and I attempted to take care of the two separate issues, but upon discussing what to do next with each of them, something told me to check a sugar level and....both of them were in the 300+ range and both were obese. Both were admitted diabetics for at least 10 years each. It turns out both were on insulin. The gentleman had insurance and wasnt checking sugars daily but stated he was last in his doctors office about 6 months ago. The ADA states to get a hemoglobin A1c every 3 months, so thats at least a visit for a blood test. I asked what is daily calorie intake was and he said about 3000. After I picked my jaw off the ground, I mentioned that a normal person is 3000- 3500 cal per day. He says it's "hard". I gave him the reality scenario of having silent ischemia from heart disease and diabetes and that dont count on doctors missing his heart, he will live and doctors will have him on machines and medicines. He will live a lousy life if it gets to that point and it will unless he changes his goals. He was more worried about getting a pain shot for his low grade back pain than the bronchitis in his chest or the chest pain. I explained that the muscles in the back and the bones in the back wont heal if sugar is constantly floating around in the blood stream and not getting into any cells the heal.

The young lady was in for a new absess to her neck and was a very nice person, she had a different story. Alot of stress lately with death of her dad, no insurance since then, no job. Had last vial of insulin but couldnt pay for new vial. Had been losing weight and was at about 100 lbs. off since 1 year. Told her that infection is the begining, with the sugar being so high and not being able to get one drop of glucose into the little white blood cells that fight infection, I could virtually give her all the big gun antibiotics in the world but we wont win since the white blood cells cant finish the job. She broke down and cried and obviously was in alot of stress. Last lecture I gave had a topic of stress and I explained how stress brings on more free radicals that produce damage to cell membranes. This leads to poor gland functions, poor organ functions, poor thinking. also opens to infection, worsening diabetes, and cancer. I explained how if sugars arent stabilized and given to the body in regular increments, all organs fail (but they do it very slowly).

Many of the problems with diabetes, blindness, kidney failure, heart attack, stroke, amputation happen due to free radical formation. When diabetics get sugars under control, great but this subset of the population does exceptionally well with antioxidants. Magnesium seems to be depleated due to the high influx of insulin stimulating the membrane cells to change permeability from the failing pancreas so this supplement also help curb wide sugar variations. Finally Chromium and cinnamon seem to make the cells more sensitive to the circulating insulin. The basics always hold true and those would be decreasing total calorie intake in addition to not hitting the body with massive amounts of food followed by times of famine. The presence of food/glucose in the blood stream will start the usual chain of hormones to be released, serotonin, insulin, growth hormone.....when the levels of glucose vary at the extremes of the scale, the hormone response will be in extremes. Think of being in a fight or flight panic, several times a day. Not healthy and would eventually depleat all the hormone supplies causing poor sleep, poor concentration, anxiety, diarrhea, hallucinations. Remember vietnam vets and post tramatic stress disorder. Not just the mind but also led to poor health, poor social skills and poor tolerance for change.

Diabetes is a growing epidemic, almost one in three are overweight in the US. Usually the big three always come together; diabetes, high blood pressure, high cholesterol. And guess what....all related to diet. And guess what else, doctors usually dont have time for nutrition counsel but have just enough time to discuss medication side effects and new prescription use. We werent trained properly in school and residency. And the good nutritionists arent covered by insurance. Thank god for and all the info on the website. Whether on insulin injections or pills or nothing at all, food and diet are always supposed to be the basic building blocks. With all the medicines in the world, if diet isnt changed disease will continue to deteriorate. I am really worried for both of them.