Saturday, November 22, 2008


Talked to my daughters classmate mom and she claims the allergy doc did a bunch of tests and all were normal but the diagnosis was still a pertussis infection. She had been out of work (stewardess) for about 3 months. Now she is a little better but still with a hoarse voice. Also the asthma that has been "dormant" since childhood is back. Doc placed her on 2 rounds of big antibiotics and is about to do it again. I told her she needed a probiotic with all that normal flora destruction, omega 3 fish oil and probably digestive acid aid. She had very good trust in her doctor but it sounded as if the doc was just blaming it on a tough bacteria and a resurgence of asthma. Obviously the doc did the right thing for looking into was caused it but probalby should have continued on with my suggestions.

In western medicine, rheumatologist do agree with the start of some reactive arthritis issues with an infection. The issue comes up as is it the infection that begins the arthritic condition or the use of antibiotics the starts it. Probably a little of both but the "Saguil Approach" always includes a probiotic to follow the use of any antibiotic. Another doc in the ER does the same with the patients she sees and I applaud her for it. I also think that patients going to the ER for terrible symptoms also expect to get a script of two before they leave to feel they got a reward for waiting so long in the waiting room. An extra 5-10 minutes usually would educate a family on why antibiotics arent always good but I am supposed to see an average or more than average of 3.5 patients per hour to show I am pulling my share of the work load in a months time. Even out of a private practice into an ER, statistics and numbers are always the way administrators determine if we are doing are job as docs. Saving lives, getting people healthier just doesnt work in the insurance business.

I give up!

Friday, September 5, 2008

The Doobies

I had a guy argue why he takes marijuana. States he functions better at work, has less inhibitions, sleeps great and has great sex. Seems like a wonder drug right? His argument was backed by a very stern determination to trump me and my medical knowledge. He was expecting to hear the usual horror stories of how drugs are bad and conservative opinion usually comes from those that are "straight" church going parents. I side stepped that and asked him if remembers being verbally abused, physically abused or bullied in highschool. I could see he wasn't ready for that rebuttal.

I simply told him that an "average human" can function in a 9-5, interact with a spouse, and sleep without a pill or bottle or weed. When we have to supplement our lives with anything, it is usually because something basic is missing. Just like my 2 other posts this month on vitamins and Monavie, even with supplements, one still has to establish basics for the body to work right. Coming up with which basic is missing in those that require marijuana for getting through the day is very tricky. In the medical field, there are specialists like "Dr Drew" who deal with addiction medicine and very well versed with knowing what would probably work best to define issues with those "who use". It takes alot of trust to open up to a stranger, it also takes a lot of trial and error to find a therapist or doctor you feel you can open up to.

The biggest step is to realize using marijuana means there is a medical reason for the desire to keep going back to it. The next step is to see a medical provider for guidance. A primary care doctor should be the first step. Unfortunately, it will usually require a family member or loved one to bring the problem to the users attention. If nothing is done, the problem eventually will compound since stress and life trials will always get worse as we get older and our worlds become more complicated.

The last thing I mentioned to him is.......look at Bob Marley, he died using weed.

Wednesday, March 5, 2008

Waste basket diagnosis

When I was in my sportsmedicine fellowship, I used to see a small collection of patients come into the office as a referal complaning about shoulder and neck pain. Many times it would have been fully worked up by the primary care doc and with minimal signs (if anything) on xray and mri. The usual diagnosis would be that of an issue or problem with the joint involved most. Many times it would be shoulder bursitis or pinched nerve of the neck. We would again get them into therapy, thinking the therapist used by primary care was doing something wrong. Sometimes an attempt at different medicines, often stronger, and maybe a steroid injection would be attempted. After another exhausting work up to look for neck or shoulder pathology (without finding anything) and yet a patient that is still suffering, a diagnosis of a mental disorder or a malingering patient just trying to get money from the car accident or the government was made. The average age of onset is usually 20's but patients are into 30-40 with chronic pain.

Symptoms were usually the same: poor sleep, fatigue, multiple trigger points to muscles (mostly back), depression and headache. There is usually a trigger event like an accident, infection or stressful time of life. I found a diagnosis of fibromyocytis, also known as fibromyalgia being kicked around that lumped all these patients together. So actually other doctors were getting the same kind of patients and wondering if there was a syndrome that was being missed. Somehow though, it was thought of as a waste basket diagnosis since it wasn't "real" and was just coined so doctors could identify that a patient was suffering from something. Western medicine couldnt do anything with it short of sending the patient to a psychiatrist for psych meds. Being in sportsmedicine, I would utilize very gifted physical therapists that would have an eye for finding movement disorders and they would usually be able to help a patient get mobility back and work on flexibility. This alone would make many people feel better than they every had thus less medicines and eventually less side effects from medicines. Usually when a patient began to believe in themselves again, outlook would be better and they would be more involved with what works and get healthier. At one point, I had alot of patients with this diagnosis coming to me. I have to admit, I did get burned out since the diagnosis comes with many complicated issues and sorting things out took alot of emotion out of me. It was always rewarding to get the patient pointed in the right direction and see them get off medicines but if this took 45-60 minutes to evaluate and a family practice doctor that works for a hospital is expected to see a patient every 10-15 minutes.....I would get very backed up for the day. "Dr Saguil is running behind" was a common statement in my office (but patients were willing to wait! and I wasnt sure why they waited so long! I guess it was because I was listening and giving them some useful guidance.)

In a few years the American College of Rhuematology backed up the fibromyalgia diagnosis by saying that if someone came in with no other medical problems (like hidden hepatitis or arthritis) if they had sleep disorder, depression and 11 of 18 painful areas of muscle to specific areas on the body, the diagnosis was true. This was a "touchdown" for people with FibroMyalgiaSyndrome since a big authority said it is true and can be treated. Guess how it was treated, medicine for sleep, medicine for depression and physical therapy! So now the rhuematologists were getting all the referals instead of the orthopedic surgeons and they were doing the same thing.

Fast forward to the millenium, big difference now is the sprouting up of pain clinics! FMS is still being diagnosed but since its a very well documented disease, any average doc is treating it with a medicine for sleep, a medicine for depression and immediate prescription writing to see a therapist.....oh and a muscle relaxer and narcotic. Note....narcotic! Patients are being treated more readily by the unexperienced doc, usually adequate at first but with the next flare up, (and it is a lifetime diagnosis so a flare up is going to happen 1-3 times a year- especially in chicago), the frustrated doc is going to give potent medicine to quiet things down, but depending on the intensity of the flare, and other issues at the time, a narcotic will be relied on probably a little to much. Then comes the fast food mentality. Patient not educated on how important it is to get the fire put out immediately before resuming work and/or child care so reliance on meds like muscle relaxers and vicodin becomes more of the daily medicine than the "only for emergency" medicine. Then when the patient calls for a refill....referal to the pain clinic for narcotic management.

Don't get me wrong, the pain clinics are good, they did have a great headstart but they are now being dumped on by every doc that doesn't have the time to care for the 20-40 year old women (and rarely- men) with FMS. There are waiting times of up to 2 months before a patient can be seen. If you have ever suffered from a trapezius that is numb, tingling and a trigger for headaches and nausea, you would understand that just taking a muscle relaxer and popping a narcotic to get to that Jimmy Hendrix level of being high doesnt cut the pain and dysfunction. I have experienced this and it came after the emotional separation of me from my practice in 2005 when my previous hospital said they wanted to cut my pay since I wasnt producing like the docs in the rest of the country.

Suffice it to say, while in florida, I was finding the same suffering from FMS and because there werent as many "creative" docs there, I had no competition for patients but there was also great acceptance by patients for alternative medicine docs. The patients were getting smart and going to other forms of healing and getting better. Acupuncture works (no matter what a standard questionnaire says), mind body strengthening helps, movement like tai chi or the more popular yoga is a must and nutrition education is mandatory. You can always go the the pain clinic, get hard medicines for a few months, maybe a steroid triggerpoint injection her and there while you are on your way to flexiblity and healthy living.....or....just start with the movement, nutrition, time off and skip the narcotics.

Lets see where patients get dumped in the next decade.....with the government approving some alternative medicine therapies, may not have to get dumped anywhere since education is being given by those who dont have as many time constraints on visit time and those same....only can rely on movement since aggressive medicines are only given by doctors. I do believe there is a place for everything but not in excess and again I maintain it always starts with a good history and physical.

Wednesday, February 20, 2008

Breakin up is hard to do

6 fractures yesterday! Thats aside from the usual sickness, pains injuries patient list to the ER/Expresscare. Funny thing was they were all the same bone. Histories were all the same, older lady was out doing the usual activity. Just so happens the snow fall day before wasn't bad but the temperature and wind chill was very low. All of the women fell onto their butts or forward. Outstretched hand to catch and stop the fall and wrist pop with extreme pain. All came in and had terribly deformed and shortend wrist and hand. Xrays all showed distal radial fracture. 3 were right and 2 were left, (the last fracture of the day was a right hip). Luckily enough for the first fracture, an orthopedic surgeon from M & M orthopedic was outside in the parking lot and came back in to reduce (straighten) and cast. The other 4 women had to be splinted and sent to the ortho office. One of the ladies with HMO had to go the the primary care doc first then get a piece of paper then call to get an appointment to the ortho (an extra few steps that probably took 6 more hours!-is it worth it the extra hassel?)
The final lady with the hip had to stay until surgery (from Castle Orthopedics) to correct the hip.

I had a discussion with one of the nurses, funny about the onslaught of fractures, is there a correlation to time of year? Well, most obvious is the ice condition but my point is would the ladies have tolerated the fall without a fracture if they had better calcium and vitamin D? Much of the new literature states in the states above the imaginary line from virginia to san fran, people in the winter suffer more cardiovascular problems due to decreased sunlight and less vitamin D being made by the skin. It has also been studied with a coorelation ot fractures. More evaluation has to be made but now that the ladies are fractured, they will be on vitamin D and calcium for the next 2-3 months, (none had calcium stone issues). They will probably be in a cast, on pain killers and in physical therapy.

The Saguil Approach would be: prepare for a fall with good traction shoes, snowsalt and shovel access, balance exercise (tai chi is excellent) and increase the vitamin D and calcium supplements from halloween to easter. A blood test for levels before starting and after about 2 months of starting is good. A DEXA scan for a baseline bone density level is always helpful if there is question on bone being thin. The US Preventive Services Task Force suggests:

-all postmenopausal women under age 65 who have one or more additional risk factors for osteoporosis (in addition to being postmenopausal and female)
-all women age 65 and older regardless of additional risk factors
postmenopausal women who sustain a fracture
-women who are considering therapy for osteoporosis if bone density testing would facilitate the decision
-women who have been on hormone replacement therapy (HRT/ERT) for prolonged periods

Once it is found, those medicines that force bone to absorb calcium have to be used for 2-3 years! Takes that long to show effects. Better to be ready and stop smoking, decrease caffeine, weight bearing exercises, Vitamin D and Calcium supplements (if no calcium stones).

(Please see my discussion = Vitamin D in my herbal411review

Tuesday, February 12, 2008

Slow ride, take it easy!

-by Foghat

This one sling shots off my previous discussion on sept on "hitting the Wall". Nice couple came in and a guy in his mid to late 30's had a bad headache. Claims it was tolerable but he started with left eye twitching and became worried. Looked alittle overweight, dressed ok, not disheveled but could use a makeover. Wife pretty, good weight, possible smoker. He wasnt in distress andjust wanted to make sure it wasnt cancer. No history of it but he didn't want to be the first and has no time to get sick. I cleared him with an extensive physical exam and in history apparently had a history of headache like this before and worse. Doesnt complain too much and has a high tolerance for pain. Turns out he also has recently worsened his already poor sleep, drinking about 1 and 1/2 pots of coffee a day, no time to eat right. Has been heavier but is overweight and has no time for exercise with 50-60 hours a week of work. Cant take time off since someone will be pissed off with himat work. Wife says he has been stopping breathing at night with sleep.
So everyone reading can see where I am going with my diagnosis. I reassured him of the high possibility for headache due to sleep disorder, sleep apnea, caffeine dependance and SAD. Certainly cant rule out a brain tumor but with everything else occurring, I told him likelyhood of morbidity from the other previous problems mentioned is high. If he keeps up the pace over the next few years, he will be on several medicines by 40y/o. Told him if he cant afford the switch in careers now, better start saving up money over the next 8-12months and go back to school. (he already told me with the increase in weight, he has been told there is a blood pressure issue).
The Saguil Approach is to put bandaids on most of the symptoms with the understanding that he shouldn't be on the medicines for more than a month. (I fear with alleviation of some basic symptoms he will continue on his lifestyle direction and just rely on meds) Medicines are always a short cut but only to allow an avenue for the body to heal and get stronger with nutrition, sleep and exercise. How does he do this with all the obligations? I dont know that answer. I can only jump to the future and one road he may end up on is diabetes, high cholesterol, high blood pressure and sleep apnea. At a minimum, 2-3 medicines and a sleep mask-(not to mention viagra). Many docs and patients for that matter, get the bandaid meds but are given refills for a long duration since they have no other alternative than to continue with the meds for symptom suppression since they keep on returning. It does take alot of sit down time to get the point accross that the road they are taking is going to a bad place. Most docs and patients dont have this time.
We-(the docs) usually give this "face to face" time when the diagnosis we find is terminal and time is short. When noone is going to die soon, most find it hard to schedule a family intervention and it is also very demanding on the office staff to coordinate. This is ashame but when the patient cant make a job switch and the doc cant afford staff to make extra phone calls, the short cut is taken. I have spoken about the truncated interactions with the doctor and how its easier to prescribe meds than do 60 minutes of counseling in the past and it seems this is where medicine in now. There are places you can get more attention but it typically comes at a premium and is cash up front. I think its worth it especially if eventually the visits are only 2 times a year when health is improved. (Compared to insurance premiums for a family approaching 800-1000 dollars a month even without having to see a doctor!...thats just the premium to maintain the insurance policy!) I should stop now before I get on my soap box about industrialization of the bond between doctor and patient. Placing a value on and "interaction" is impossible no matter what statistics say. Every high level medical officer will always refer to statistics when explaining how the average patient and doctor visit should be in the US. Then that same high level person will make a phone call to a personal doctor as soon as he or his family gets sick all the while bypassing all the hurdles his administration has set to care for people in a timely manner since the numbers speak for themselves. I remember one of the board members in a previous hospital, pushed to save money and close the express cares during times that were nonproductive, then the rumor was when his kid was sick and he couldnt avail of the expresscare in his neighborhood, he complained and magically of the all the expresscares with the hospital, his local expresscare stayed open later than the others!

The Saguil Approach:
1. see a doc to make sure you are not going to die
2. take some bandaid meds for a designated time period
3. get deeper sleep with meds or herbs or a vacation or medical leave
4. get off red meat and eat more veggies....depending on the season, I like dominics, target and of course whole foods. Trader joes and the local farmers are also popular.
5. save money now for a possible layoff for 3 months(this would be the amount of time to find another life style or the same job but a different place.
6. stress reduction, exercise, sleep and family spirituality have to be learned, can't get it in a prescription....try working in a homeless shelter, the va, or a cancer center and it will ground you that life isn't that bad that you don't have a choice.

Sunday, February 3, 2008

Just like ole times.....

Got a call from old friends/patients in Wheaton. As I was at the ER/Expresscare working, came accross a note from one of the old families I used to take care of in Wheaton. First I thought, oh's bad news. (I can't imagine what it's like to have a loved one in Iraq and getting a call from the government!) When I got some time, I called to get the news from the frustrated wife. My old friend; retired airborne armed forces patient, had gone to see a good neurosurgeon collegue of mine. (This was a doctor I rotated with when I was at Cook County Hospital visiting from the philippines trying to experience Traumasurgery and Neurosurgery. He was chief resident then and very meticulous; when I came back to Illinois to practice medicine in '95, he was at the same hospital! Excellent surgeon, great bedside manor, all around nice guy....and here he is again back in my life somehow.....for those who read the "Secret"...this is the law of positive attraction!) Anyway, my old patient had back pain and went to see Matt. The MRI showed 2 discs, so with intractable pain failing conservative treatment, the next step was to fix. Unfortunately, he still had pain and now muscle atrophy psot surgery. After getting all the info on what had been ordered and attempted in the last 3-4 months, everything was correct and my only reply was (in my cup half full reasoning) least it wasn't cancer! In the midst of all his pain, after having gone through corrective surgery, physical therapy with the best and to be unchanged with his pain, the last thing he wanted to hear was "it's not that bad".

But it is true, he isn't going to die..... but he isn't getting sleep and has 24 hours of pain. All I am thinking is that..."great, if Matt has worked his magic and found no surgically corrective issues, my turn!!! I started rattling off everthing I wanted to do in order, just because I have been down this road before. Even when I didn't do as much integrative medicine, I was still using all my non surgical possibilities to help patients and guess what, it was about the same thing. Listen to what the patient was complaining about, interpret what the true issue is, fix the sleep, give hope, insure proper nutrition and start rehab(movement/flexibility).

Here's the message boys and girls, no matter what the medical issue is, always need to support the basics: nutrition, sleep, movement, spirit. Even if the skilled surgeon is involved, still need those basics satisfied or else surgical outcome will be poor. Sometimes in preparing for an ACL reconstruction like in football, the therapists will do what we call "prehabilitation". This is getting the muscles and joints tone and strong enough to go straight into therapy after surgery. We can take this same concept and use it even for smaller issues. Prehab for surgery, chemo, travel, new medicine trials, starting stressful times in life or even before starting antibiotics for a cough. Outcomes will always fare better when the body is prepared.

So I am sending Bob to an acupuncture friend of mine =, (I still don't have a physical space set up yet), the therapist will hopefully be able to get a TENS unit for the patient to use hourly, I will add a gentle muscle relaxer and then suggest and herbal antiinflammatory (he is on a blood thinner and regular nsaids can't be used). The most help I probably gave him was a chance for improvement. When western medicine stops, eastern medicine continues on! It's amazing how this gets me energized also!...I'll keep you informed on how "Bob" does.