CT scans done in ER – up 6-fold from 1995

Did you know it used to take NINE DAYS to finish a CT scan?

Look how far we’ve come: Increased utilization, increased risk, possibly increased cost. Increased reassurance?

Interesting article (see link to the NPR article below). The number of CT scans being done in a year is staggering and is a reminder to be judicious with the use of imaging.


Tryptophan in the Turkey: A Whodunit (part 2)

See (https://pulsus.wordpress.com/2010/11/27/tryptophan-in-the-turkey-a-whodunit/) for part 1.

The story I crafted in the preceding blog was an exaggeration of the well-known phenomena that occurs across the country after eating Thanksgiving turkey. It was inspired by my nephew, who heard about tryptophan in turkey causing drowsiness. The question of what was responsible for the unconsciousness of the guests around the Thanksgiving table in my story is a little tricky, really.

Turkey does contain high levels of tryptophan, which is an amino acid (a building block of protein) and converts into serotonin. Serotonin is a precursor to melatonin, a hormone that helps regulate our sleep-wake cycle by causing drowsiness. The interesting thing is that the amount of tryptophan in turkey is comparable to the amount in other poultry and meat – equivalent to the amount in chicken, and slightly more than the amount in pork, for example.

The real cause of our drowsiness after Thanksgiving dinner is not all that straightforward. Of course alcohol causes drowsiness, so that must be taken into consideration. But we have to look at what happens when we eat stuffing, mashed potatoes, sweet potatoes, bread, and cranberry sauce. These particular foods (high in carbohydrates) increase our levels of insulin. Insulin helps bring our sugar levels down, but also decreases the amount of certain proteins circulating in the blood by stimulating uptake into muscles. However, tryptophan is not one of those proteins. This leaves a higher percentage of tryptophan circulating in the blood after this type of meal (relative to other proteins). Thus it has a greater advantage in  crossing over into our central nervous system… turning into serotonin….

then melatonin….

you get my drift. (Hopefully not drifting into sleep, though? I will end this shortly).

As far as my multiple choice question from the last blogpost (https://pulsus.wordpress.com/2010/11/27/tryptophan-in-the-turkey-a-whodunit/):

What was the cause of the loss of consciousness of the guests at the Thankgiving table?

A. The wine

B. The mashed potatoes

C. The turkey

D. The maid

E. The butler that was never mentioned

F. The doctor (gasp!)

G. A, B, and C

H. Not enough information to determine

I would have to say “H” is the answer. This is because I have not heard or read of any cases of the tryptophan effect causing a sudden loss of consciousness. As my story was completely fictional, I took the liberty of dramatizing my point.

I hope you had a wonderful Thanksgiving holiday and, if you want to avoid the drowsiness effect next year, I would recommend that you consider eating fewer carbohydrates with your turkey.

Tryptophan in the Turkey: A whodunit

The place:  A large home in an undisclosed location.

The time: around 7pm on the fourth Thursday in November.

The story:

The guests, clad in their holiday finest are crowded around in merriment – glasses clinking, voices laughing, music playing. The host surveys his large dining table and notices that one chair is empty. Nevertheless, he raises another glass of wine and offers his toast, “Today, I give thanks to all of you, my dear friends and family, who bring happiness to my life.”  And with that, he signals the maid (who has been toiling all day over this Thanksgiving meal), to serve the food. The guests “ooh” and “aaahh” as the centerpiece, a large golden-brown turkey, is placed in front of their eyes. Adorned with roasted parsnips and carrots and accompanied by various delectable dishes – such as hearty wild rice stuffing,  creamy mashed potatoes, and brussel sprouts bathed in butter – the turkey does not go to waste.

The guests fill their stomachs and begin to slouch slightly in their seats.  “Where is dear Doctor Higgins? He always arrives late, but this is quite unusual,” one young woman said with her eyes appearing quite heavy. “No matter,” she says. “We must dance and continue our festivities.” And with that, her heavy head suddenly drops, her brown curls arranged like a fan on the table. The maid rushes in breathlessly, hearing the sound of the water glass crashing to the floor, and stops in shock at the sight. The gentleman to the young woman’s left also becomes unconscious. In a matter of seconds, the whole table falls into a deep coma. The maid screams in fright, then promptly falls to the floor with quite a loud thud.

            At that moment, the main door opens and a blustery wind forces itself in, along with the long-awaited Dr. Higgins. “I do apologize,” he mutters, as he pushes his brimmed hat off of his face, completely unaware that the room is silent but for the music playing in the background. When he finally looks up, he drops his worn, black doctor’s bag as he witnesses the strange sight.  “Oh, dear!” He said. “There appears to have been some foul play! But who is responsible here?”

What do you think is the answer?

A. The wine

B. The mashed potatoes

C. The turkey

D. The maid

E. The butler that was never mentioned

F. The doctor (gasp!)

G. A, B, and C

H. Not enough information to determine

(to be continued….)

A Top 10 List for Thanksgiving

The Top 10 reasons I am thankful I am a primary care physician (tongue-in-cheek, Letterman-style):

10. I have a corner office

9. I share this cozy corner office with three colleagues, while the poor orthopedist down the hall sits lonely at his large-custom made desk in his spacious room.

8. I have an active brain. As the old saying goes, “use it or lose it.” (But I occasionally wonder if I will sustain a new form of repetitive use injury).

7. Paying off medical school loans in monthly mortgage-sized increments teaches me the value of money.

6. I get to go to the bathroom during a 2-minute break at lunch.

5. I get to be a second opinion to Dr. Web, Suzanne Sommers, Dr. Oz, and Oprah, among others.

4. I get to see and hear almost everything under the sun.

3. My efficiency at listening and talking has spilled over into my personal life. At parties, I have an internal clock that tells me that time is up and I have to move on to the next guest.

2. My sleep-depriving career has kept me from developing insomnia.

1. I am at lower risk of getting hooked on drugs than an anesthesiologist.

All kidding aside, I hope everyone has a wonderful Thanksgiving.

Stay safe, healthy, and warm!


New guidelines on the “whooping cough” vaccine

I recently went to the American College of Physicians Chapter Meeting in Seattle and came away with a lot of great information, including a significant change in immunization of adults against pertussis (whooping cough).

When patients need a booster of tetanus immunization, we often give it in combination with a vaccine to protect against pertussis. As you may know, tetanus is a life-threatening infection by a bacteria that can cause severe muscle spasms and lockjaw. Immunization boosters for tetanus (Td) are given every 10 years to prevent the life-threating tetanus infection that can causes severe muscle spasms and lockjaw. The Tdap (tetanus-diphtheria-acellular pertussis) vaccine is a combination vaccine that helps prevent both tetanus and pertussis and has been typically given to patients aged 11-64 when they were due for their next tetanus immunization (if they had not received it yet).

Unfortunately, we are seeing a rise in whooping cough. In California, there have been more than 6200 cases and 10 deaths related to pertussis. It is also on the rise in other states. Often, it is grandparents and siblings that pass on pertussis to infants. For this reason, the recommended age group receiving the Tdap shot has broadened. Although the Tdap is not approved for adults 65 and older, research has shown that these vaccines are safe in this age group. Also, there is no longer a required interval between the Td and the Tdap vaccine (which used to be 5 years).


*People aged 11 to 64 who have not received the Tdap should get it, even if they are not sure when they last got it.

*Ask your pediatrician about immunizing children who are younger.

*I would strongly urge that adults 65 and older who are likely to have close contact with an infant also get the Tdap vaccine if they have not received it or even if they are not sure that they have.

What’s Fueling You?

With the darker days upon us, it may be tempting to try to fight fatigue with energy drinks. Ever wonder what’s really in them and what they might be doing to you? I just came across an article in the November issue of the Mayo Clinic Proceedings that broke it down nicely. Here’s the summary:

CAFFEINE.  No brainer. Interestingly, it is on the list of substances banned by the International Olympic Committee (which is just another reason you won’t see me in the Olympics). Most energy beverages (EB) contain 70-200 mg of caffeine per 16-oz serving. There is 65-125 mg in percolated coffee. Caffeine increases heart rate and blood pressure. If you drink more than 200 mg at a time, you may experience insomnia, nervousness, headache, abnormal rhythms in your heart, and nausea. Absorption is very rapid and the half-life is quite variable (from 2.7 to 9.9 hours). That morning coffee could still be “in your system” in the late afternoon. Whether it really dehydrates you is controversial and it seems that this not as likely if you are a regular caffeine drinker.

TAURINE – an amino acid (which is a building block of protein). We have tons of it and it is already in our diet. It helps the function of our muscles, among numerous other benefits on a cellular level. The amounts that are in EBs are not enough to be particularly helpful or harmful.

GLUCURONOLACTONE. Don’t try to say or remember this one. This is made in small amounts within the body. Not much is known about its effect in humans.

B VITAMINS. (thiamine, riboflavin, niacin, pantothenic acid, pyridoxine hydrochloride, biotin, inositol, and cyanocobalamin). These are important for proper cell function and energy production. Cyanocobalamin, in particular, is important in formation of red blood cells and helps maintain nerve cell function. A common deficiency we see is cyanocobalamin (B12) deficiency. When a patient has been fatigued, we take a look at the red blood cells to see evidence of B12 deficiency.

GUARANA. This is a rainforest vine and guarana fruit seeds contain more caffeine than any other plant. The Amazonians used it to increase awareness and energy. Guarana overdose has been known to occur and has sent some people to the ER.

GINSENG. There are a fair amount of adverse effects with Ginseng, but the amounts in EBs are not significant.

GINKGO BILOBA. So far, there is no evidence that it has any particular health benefits.

L-CARNITINE. This is also an amino acid. This is made by the liver and kidneys to increase metabolism.  But there does not appear to be any benefit to taking more than a certain amount because we can only absorb so much at once.

SUGARS! Yikes. There is a lot. One typical EB (500mL) can has 13 teaspoons of sugar. I don’t think I have to say more about why this is not good.

ANTIOXIDANTS. There haven’t been any significant effects in well-trained athletes when they took antioxidants.

Remember that these drinks are unregulated and often the amount of every ingredient is not known.  No more than 1 can a day is recommended (if that).

Other notable precautions:

–          EBs can cause seizures, cardiac arrest.

–          In one case report, a healthy 18-year-old died playing basketball after drinking 2 cans of Red Bull

–          Red Bull has been banned in Norway, Denmark, and France

–          Energy drinks can reduce symptoms of intoxication, increasing the probability of accidents and alcohol dependence, similar to Donte Stallworth’s story: http://sports.espn.go.com/nfl/news/story?id=4311675

SO, if you are going to drink energy drinks,

DO NOT drink energy beverages while exercising. 

DO NOT mix EBs with alcohol.

DO NOT use energy drinks if you have high blood pressure or other heart condition.

And remember to let your doctor know if you are drinking energy beverages or taking other herbal medications. Always ask your own doctor for advice.

“The Vanishing Oath”

I had to buy this movie after I saw clips of it on the web. Below is the review I wrote for Amazon.com.

In “The Vanishing Oath” Ryan Flesher, MD, bravely invites us along with him as he struggles to overcome feelings of burnout and disappointment in a profession that has required years of sacrifice. Along his path, he finds other physicians – even quite early on in their careers – with similar frustrations and disappointments. He touches on the factors that have contributed to physician burnout, as well as public perception of physicians. The movie presents statistics and projections that paint a somber portrait of the future of medicine for physicians. Despite the high stakes and expectations that come along with being an ER doctor, Flesher exposes the very human side of being a physician practicing medicine today.

“The Vanishing Oath” is a movie that should be seen by anyone who interacts with physicians. Based on our hopes for health care reform, this would be everyone in this country in the future. But any health care reform movement would be remiss if it did not take into account what is going on in the minds and hearts of these individuals on the front line. Bureaucracy and the “business of medicine” have resulted in a silent departure of physicians from clinical work.

Despite its overall solemn tone, and lack of real solutions (which mirrors the reality that Flesher is presenting), this movie is inspiring because it is a timely starting point for open dialogue about this heretofore quiet movement. Because the quality of healthcare is only as good as its providers, we need to find ways to prevent an exodus.

*For info regarding the film and purchasing a DVD: http://www.crashcartproductions.com/