On a stressful shift one evening, a colleague—we will call him Dr. X—had a woman sign in to the emergency room complaining of knee pain. On exam she was a large (obese), late-middle-age female with bilateral knee pain. She told Dr. X that her knees were getting progressively painful and stiff over the past few months. She had an obvious “valgus” deformity, which describes an inward bend to each of her knees; this condition is often seen in woman and often exacerbated by an overweight frame.

ER Diagnosis

After a number of tests and X-rays, it was clear to Dr. X that his patient was in the early stages of osteoarthritis, a condition that is common with “wear and tear” of the joints, the aging process, repeated injury, and obesity.

James M. Bregman MD is an Emergency Physician at White Plains Hospital in New York. He has been on staff there since 1993 after completing his residency at Montefiore Medical Center, N.Y. He’s also an adjunct professor at Pace University’s Physician Assistant Program.

He had ruled out inflammatory conditions by blood work analysis and a good physical exam and history. He took routine X-rays, which demonstrated mild degenerative changes and changes related to the thinning of cartilage and narrowing of joint spaces between the woman’s femur and tibia. These changes are typically seen in early osteoarthritis and chondromalacia (degeneration of the cartilaginous cushions of the joints).

Dr. X conveyed these findings to his patient and reassured her that her knee pain was not the result of an acute injury, and that she likely needed no extreme intervention and surgical correction. He did, however, carefully convey to her that excessive weight on her joints was a major exacerbating factor for her knee pain. He suggested that less force or weight on her knees could ease her pain.

Dr. X also referred her for orthopedic follow-up, suggested that she take ibuprofen and acetaminophen for pain as needed, and try a gentle walking program when her pain lessened. He discharged her into the night and went back to seeing patients.

How Stress Can Affect Medical Etiquette

The following evening, Dr. X was surprised to hear from the triage nurse that this very same patient was signing into the ER to be re-evaluated for the same mild knee pain. This woman returned to the treatment area and threw him a look of dissatisfaction. “Doctor” she said, “my knees still hurt so I came back.”

Dr. X, somewhat stressed and a little exasperated, quickly re-examined the patient and quickly came to the same conclusion he had the night before.

Aching knees? For the woman who became a repeat visitor to the ER, the condition was related to extra weight—but wasn’t actually an emergency situation.

The ER, in the meantime, was getting busy. The department was expecting an ambulance that had just called and was several minutes out. Dr. X explained to this patient again that excessive weight and mild, progressive arthritis were the cause of her discomfort. He explained that there was nothing more to do on a Friday night at 11 p.m., and that she had no emergent condition that warranted further treatment or testing. He again discharged her from the emergency department and proceeded to see other patients.

At this point in his story, I was somewhat bored and wondering, “What was he getting at?” I had encountered many patients like this, and it seemed like a routine and rather uninteresting medical encounter. But he had more to this story.

On the following night—his final of four consecutive 12-hour shifts—Dr. X was trying to hold his own on a busy, chaotic Saturday. He was tired and even more stressed than on the previous night, and the department was short-staffed. Three ambulances had arrived within the past hour, and things were really starting to “come apart at the seams.”

I have been there myself. Nights like these can be exhausting and emotionally draining. It’s a rough ride, and will leave you feeling like a wrung-out sponge in the morning.

To Dr. X’s surprise, he came out of a room with a seriously injured patient and was again confronted by the woman with knee pain. She had signed in again for the same ailment—chronic, mild knee pain—and approached him, saying he hadn’t helped her. At this point, Dr. X was frustrated, flabbergasted, and annoyed. His stress and emotional exhaustion was taking its toll on him.

The woman, who had walked into the ER on her own, explained that she wanted to see him again and have him look at her aching knees. Dr. X was at the end of his rope.

“Madam,” he said, “do you know how, when a whale is stranded on a beach, its little fins can’t bear the weight of it massive body? Well, those tiny little fins can’t free the whale from the beach, and may become painful and damaged. Madam… your fins hurt!”

Needless to say, she stormed out on her painful knees, and Dr. X quickly realized he had crossed the line. He told me it was a watershed moment in his career, and that he probably needed to cut back a little and re-think his approach. (He was questioning his judgment as he told me this story because, perhaps, we were lying next to each other on cots, in a desert, in a rat-infested, dusty plain 320 miles south of Bagdad (another story for another day.)

Medical Etiquette: The Fallout

The morning after he had insulted his patient, Dr. X awoke to a message from the vice president of his hospital. The message asked him to call as soon as he got a chance—and even said, “‘Your fins hurt….’ Really?”

Dr. X had to respond to this complaint in the form of an apology letter and an explanation to the administration—and received a letter of admonishment in his file.

He was able to move past the incident with self-reflection and shame, and perhaps a slight dose of humor. It was a lesson for him and a learning experience for those of us who have heard the tale.

The situation that led to the “fins” comment describes a challenge that confronts many of us in the Emergency Department. Stress, anxiety, and frustration can come together at times like that, creating a response or reaction that may not be professional or appropriate.

In light of Dr. X’s story, the learning points, for me, are obvious—and they’re points I can pass on to my students.

Expect Etiquette with Medical Advice

Going forward, I continue to try to be patient, to avoid confrontation, and to notice when stress and exhaustion are taking their toll on me. I am sometimes successful, but I strive to get it right all the time. I try to find a balance between correct, compassionate care… and an approach that is sustainable.

Many of my colleagues get it right on a more regular basis, and some do not. We, as physicians, are individuals of different personalities and temperaments.

Beyond Medical Etiquette… The Stress of Extra Weight

Now, back to the medical issue at hand: Physics does not lie! People who are overweight place a much higher load of stress on their joints and other parts of their bodies. There is an accumulative, physical toll that occurs when daily stresses imposed by gravity are increased by obesity and poor muscle tone.

Newtonian physics dictates that forces on the cartilaginous cushions protecting bones and joints will get compressed, chaffed, and degraded over time. Not one of us can escape this physical equation. We can only mitigate or slow the process by reducing the forces on our joints and improving the health and nutrition that impact bone and cartilage regeneration.

Our family genetics also play a role as to our inherited anatomical “bank account.” That is to say, some of us will have healthier, more resilient bones and cartilage. We can enhance what we have with good diet, clean living, and healthy exercise, but all of us will increase the rate of bone and joint degeneration through poor weight control and obesity.

We in the medical community must compassionately explain that excessive weight and obesity should be addressed so that other aspects of a patient’s health will improve. We know that by addressing obesity we not only address the physical forces affecting bones and joints but improve metabolic factors such as diabetes, hypertension, and high cholesterol.

This is actually what Dr. X, despite his lapse in medical etiquette, was trying to say to his patient, and I believe in a different time and place, he would have done so in a better way.

This article was originally published in 2017. It is regularly updated.

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You see, in medicine we use mnemonics, abbreviations, and medical slang like they’re going out of style. I’m setting out to introduce you to the practice, one that takes in emergency rooms throughout the country each day. My diagnosis of the use of “codes” in ER settings: It’s extremely varied in severity, presentation, and anatomical involvement, but it employs a vast wealth of medical resources.

Let me illustrate the medical condition FDGB by reenacting an ambulance call received in my department on a regular basis:

“Dr. Bregman… there is an ambulance call… please pick up….”

“Hello, EMS Doc Bregman here… what have you got?”

“Hey doc… coming in with an 82-year-old female FDGB with right hip pain. Has stable vital signs, and we’re are starting a line and want to give her some morphine…. She may have a hip fracture.”

“Okay, we receive you and will be expecting you…. I’ll tell the charge nurse…. What is your expected ETA?”

And there you have it—another patient on the way to the ER after falling down and injuring herself. Oh yeah—that FDGB code: “fall down go boom.”

“FDGB” in no way is meant to be callous or cold; it’s just our lingua franca in the emergency setting. We talk over staticky short-wave and police radios, and we work in an environment that’s at a constant low-level din at best. As a result, we have developed a type of communication that allows us to compress information into short bursts. It’s not quite like the Navajo code talkers of World War II, but it’s close.

Emergency-Room Secrets: How Codes Can Help

Our physician contributor reveals an emergency room secret: “FDGB” is a code for a certain type of injury. It “in no way is meant to be callous or cold”—rather, it helps personnel react quickly and efficiently.

The considerations when receiving an FDGB are vast. A person falling off a curb or stumbling over his poodle in the house is very different then a fall off scaffolding or down the stairs.

The variation in severity of injury is apparent when considering all the different types of falls and the medical needs and approach to such a patient. A simple fall with an outstretched hand to protect oneself can result in a wrist fracture or sprain. These isolated injuries often result in a cast or splint, and can even require a surgical procedure for correct healing and function.

Conversely, a complex fall, for example, down the stairs or from a substantial height can cause multiple injuries at different anatomical sites. We call this a “multi-trauma.” There can often be a related head injury (closed or open) and/or extremity trauma and injury to the trunk, abdomen, or back. For instance, a fall down the stairs can cause rib fractures if one is sliding down the stairs on their upper side or back, and can also result in ankle injury, or more, if an extremity is caught on the way down.

In the example of the “stair tumble,” we can imagine how a person may suffer an impact to their head on a step, wall, or railing on the way down. He or she may suffer a concussion or even worse—and a loss of consciousness can be part of the relevant history.

In severe head injuries patients can have hematoma, or collections of blood that can accumulate on the outside or within the brain tissue. These hematomas (depending on the type and severity) sometimes need drainage by surgery or decompression to prevent brain injury. The various types of brain injuries are so vast that they merit a discussion I’ll save for another day. But suffice to say that these types of injuries may alter the level of consciousness of a particular patient and cause varied degrees of disorientation and even memory loss.

Falls and Fractures

When considering FDGB cases, hip fractures are probably the most common type of severe fall seen in a community hospital Emergency Department. The reason for this is obvious, if we consider the demographics of those who fall and their susceptibility to injury. It just so happens that 90 percent of all hip fractures occur in patients over 75 years of age. The elderly are not only the most likely to fall, but are also the most likely to sustain severe bone injury after an FDGB.

Unsteady gait, muscle weakness, dizziness, vertigo, Parkinson’s disease, poor eyesight, prior strokes, arthritic diseases, medications, and heart disease are all factors that increase one’s risk of falling. And those ailments often accompany osteoporosis, osteopenia, malignancies, arthritis, and the aging process in general, resulting in the weaker, less dense bone structure of this population.

Services That Help Prevent Injuries: Are They Endangered?

Considering the combination of an increased mechanism for FDGB and a greater susceptibility to fracture, it’s no wonder that hip fractures are the most common serious fall injury occurring in our community.

Programs that help seniors—who are most susceptible to falls—are important in preventing injuries.

For this very reason, resources that help the elderly, stabilize them, and improve eyesight and stability can positively impact our finite medical resources and save millions of dollars annually. Home visits by professional nurses and aides, physical therapy and devices (such as walkers and canes) designed to help the elderly ambulate safely will surely reduce falling along with many of the resultant medical complications that arise from FDGB visits to hospitals.

Such services as “meals on wheels,” senior centers, ambulette services, homecare services, and senior exercise programs have been shown to strongly impact the activity and vitality of the elderly and improve overall health, reduce falls, and save the healthcare system millions of dollars.

Quick fixes or proposed budget cuts that reduce such services often save us nothing in the long run, and are certainly not measures that improve our citizens’ lives and well-being.

Be very wary of a people who say they know how to “fix everything.” Be very skeptical of those who claim they can figure out this system in a few days or few weeks. They likely know not what they are talking about. These problems are often complex and subtle, and require some thought, insight, and analysis. I’ll say it again for those who think they know how to fix our health system: “Thought, insight, analysis”

When it comes to falls (or FDGB), the topic is vast and the problems are varied, but I believe we can all relate to the surprise, anxiety, and fear that comes with them.

Who has not stepped on a magazine, slipped on ice, stepped off an unseen curb, caught a shoe on a door jam, tripped over a low piece of furniture, worn slick slippers on the wooden stairs, or tripped over the cat? If you haven’t, you’re fortunate, but if it happens, we in the ER are here for you.

This article was originally published in 2018. It is regularly updated. 

The post Emergency Room Secrets: Falls, Fractures, and “FDGB” appeared first on University Health News.

A majority of these patients come to the emergency room with typical cough and congestion symptoms. They complain of upper respiratory irritation with a cough or mild sore throat. They sometimes complain of a little phlegm and nasal congestion. In short—a cold!

We evaluate these patients as quickly as possible in an attempt to separate them from the severe asthmatics and those who have a high fever, lethargy, or symptoms that may indicate a more serious underlying illness.

One of the most predictable and frequently asked questions is: “Are you giving me antibiotics?”—often followed by, “Doctor, I need antibiotics.”

Evaluation and treatment of these rather minor disorders by the medical community often leads to frustration as a result of the public’s unrealistic expectations and its need for a “magic bullet.” These encounters are frequent, and if we don’t prescribe antibiotics, these patients often feel inadequately treated or “short-changed.”

Our author has seen more than a few cases of patients with cough and cold symptoms stopping into the Emergency Room in hopes of getting antibiotics.

What Causes Respiratory Infections?

The vast majority of minor respiratory infections are caused by viruses and, therefore, antibiotic therapy has no place in the treatment. In fact, there’s very good evidence that overuse of antibiotic therapy not only can cause adverse reactions and side effects in a patient, but it may have a long-term negative impact on the effectiveness of antibiotics in the community.

Furthermore, antibiotic over-prescribing also may contribute to the emergence of antibiotic-resistant bacteria.

The appearance of MRSA (Methicillin-resistant Staph aureus) and other “super bugs”—including those that cause “hospital-acquired pneumonia” (HCAP)—are the result of flagrant antibiotic use and irresponsible prescribing over the past 65 years.

Antibiotics and Responsibility

The father of modern antibiotics, Alexander Fleming (1881–1955), is likely rolling in his grave as I write this piece. A gram of penicillin in his day was worth a pound of gold, and the miraculous response his potion brought to those dying of simple infections was almost magical.

Professor Alexander Fleming, who served as Chair of Bacteriology at London University, first discovered Penicillin Notatum. He’s show here in his laboratory at St Mary’s, Paddington, London. [Photo: Imperial War Museums TR 1468]

The public—wanting the best, most efficient, and fastest remedy—is oftentimes at odds with their healthcare providers for what it may perceive as a denial of quick, effective treatment. When a patient has a stuffed-up nose or is coughing phlegm, he or she isn’t usually thinking about exactly what organism or “germ” is infecting their mucous membranes. They merely want to get better. They want to return to family, work, and life. They don’t want to hear about the nuances of antibiotic use, and the great risks to the general population about the overuse of antibiotics.

This difference in perspectives between providers and patients often creates a dissonance between the two parties and makes for an adversarial rather than constructive relationship. It can result in a chain of events, feelings, and emotions that hurt both parties, thus detracting from the ultimate goal of treatment and education.

Furthermore, when a consumer is at odds with his or her healthcare provider, it can lead to negative feedback from patient to doctor and cause reduced satisfaction on surveys and Press Gany scores. Theses scores and surveys have real, concrete impact on the medical provider’s lives. We get reviewed and judged by our bosses and peers based on surveys. We get ranked and rated in websites and national lists that can then impact our salaries and insurance reimbursements.

As for patients, they only get frustrated by what they may feel are hasty, condescending responses and/or complicated and unintelligible jargon spewed by an insensitive health provider. They don’t hear us at this point.

Working It Out

What now? How do we approach this rift? How do we maintain a positive and constructive relationship with our patients?

I believe the answer is a four-pronged approach that I call “SHEC,” and it can apply to most areas of medicine. SHEC stands for Science, Honesty, Education, and Compassion.

Yes, if used correctly, SHEC can get us out of many messes and move us toward more productive, fertile ground. It can allow us, as providers, to delve into the real issues that may confront patients and loved ones in far more complex and serious situations then just a common cold. SHEC can lead to happier, healthier, and more satisfied patient populations.

SHEC: Science, Honesty, Education, and Compassion

The challenge with SHEC is that (as with many things) it requires patience and time. A doctor should sit down and take a careful history and listen carefully to a patients’ concerns and fears. We then must try to tailor our science into an understandable form so that our patients won’t feel we’re talking down to them (or above them). This can be difficult because many patients don’t want the “dumbed down” version.

A careful exchange during the interview and exam may allow one to assess what the patient may or may not absorb and the level of science they can understand. Several times in the past, I have begun to explain my simplified germ theory to a biochemist or pharmaceutical researcher, only to realize their level of comprehension may be superior to mine. Other times I catch myself talking about gram positive or encapsulated organisms to a less informed patient who may be aware that there are “germs” out there (and that’s about it).

So let’s try it (I interviewed and examined Patient “Smith” who has asked me for antibiotics):

“Well, Ms. Smith, by my exam, you have a common cold or viral respiratory infection. This infection is caused by a virus and not by bacteria, and, therefore, does not call for antibiotic treatment. Antibiotics are not effective against viruses. In fact, antibiotics can put you at further risk for side effects such as diarrhea, stomach upset, and the growth of stronger bacteria on your body.

“The virus you have will run its course in several days, or possibly longer, but there are many ways we can make you feel better and help you get better as quickly as possible. Our best approach to helping you is for you to get plenty of rest and to drink clear fluids so you don’t get dehydrated. There are some medicines you should take for fever and body aches; we can also recommend medications for your cough and congestion that may help with these symptoms.

“We will make ourselves available to you if you have any questions while you are recovering. Your body needs rest and time to recover, and I understand that you feel bad and may even be scared, but I can assure you, you are not in any danger. With rest, nutrition, and fluids you will soon feel better. Should anything change—such as your fever, breathing, or your ability to drink fluids—we can check you again and decide whether there is anything more you may need. Your body has a way of getting rid of almost all minor viral infections, and in the rare case that your symptoms become worse, we will always be available to help you further. Now, what questions or concerns do you have?”

Doctor’s Advice: Cold and Fever Symptoms

There it is. It takes some time and patience, and may not be perfectly smooth, and in some cases, it may get difficult. There is sometimes the insistent patient that will not take no for an answer. I have found, that if I take a moment and embrace my SHEC technique, things usually turn out positively.

Give cold symptoms plenty of hydration, fever-reduction help, and a lot of rest, and they often disappear in a few days.

Now for the patients to remember: Please know that almost all coughs, colds and congestion, resolve spontaneously in a short period of time (three to five days) with rest, fluids, and fever control. I can’t stress enough the importance of rest and hydration, and I believe that most people when sick, are falling short of this goal.

In the present world, we live in, we don’t want to stop and slow down when we are sick. We can’t be bothered by an inconvenient illness and we, therefore, often don’t embrace the fundamental steps that are required to get well. If we could just pop a pill and keep going, then that seems to be what we would prefer.

It is up to quality health care providers to inform us and guide us to do what is right and not just what is the most convenient.

As patients, please have faith, and allow your physician to become a better provider of your health. Have some patience and realize that recovery may take time and even be inconvenient, but you also are responsible for your recovery. The pathway to getting well may not be contained in a little pill. Have some faith in your doctor’s knowledge and ability. We, as physicians, truly want to help you.

This article was originally published in 2018. It is regularly updated.

James M. Bregman, MD, is an Emergency Physician at White Plains Hospital in New York. He has been on staff there since 1993 after completing his residency at Montefiore Medical Center, N.Y. He is Board-certified in Internal Medicine through American Board of Internal Medicine (ABIM) and in Emergency Medicine through the American Board of Physician Specialties (ABPS). In addition to his work as an emergency physician, he is an adjunct professor at Pace University’s Physician Assistant Program, the Medical Director of The Harrison Emergency Medical Services, and an urgent care physician at The Armonk Urgent Care Clinic in Armonk, N.Y.

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When I got the call to triage, the patient held out his right hand to show me. I noticed he was a “ruddy-faced” man, and that he was wearing matching ski jacket and pants. He had ski gloves clipped to his jacket, and he was with a child who was also in full winter regalia. I asked him, “Which mountain did you ski today” (utilizing my full ER Doc deductive powers). He said, “We just came back from Stratton Mountain in Vermont. We went skiing for the weekend but we stopped early because it was very cold.”

James M. Bregman, MD, is an Emergency Physician at White Plains Hospital in New York.

He said he thinks he froze his fingers when he was taking his gloves on and off to adjust the kids’ equipment. He said he skied with gloves that were too thin—plus, he got them wet a one point. He also said he was experiencing a burning feeling in his nose and cheeks.

I quickly surveyed his hand, face, and skin. His lungs were clear, his vitals normal and his face red and rosy but with a few scattered “scarlet”-looking blotches over his upper cheeks and nose. He said he wanted treatment and advice, but didn’t want to wait long. (Some things never change!)

I led the patient back to the minor treatment area to address his frostbite symptoms. I asked an ER technician to get a large bowl of warm water and some warmed compresses to apply to the patient’s face and nose. I reassured the man and said that he had some mild frostbite. I explained to him that if we take appropriate action now, he should have no major issues.

Even when prepared for outdoor winter activities, sometimes the best-laid plan take a back seat: Gloves get lost or wet, and hands get exposed and become at risk for frostbite symptoms.

The Dangers of Frostbite Symptoms

I have seen a number of patients over the years with a similar presentation resulting from exposure during various types of activities. Whether it was skiing, biking, hiking, shoveling snow, snowboarding, or other goings-on, there is always a common path: prolonged exposure to wind, cold, low temperatures, and clothing that was inadequate.

In most of these cases, I diagnosed frostbite or frostnip, which describe localized tissue hypothermia. It is usually mild, and it usually has a good prognosis.

A recent case I wrote up described serious, life-threatening hypothermia (see “Hypothermia Symptoms: An ER Doctor’s Tale of a Patient in Dire Shape“). For this discussion, I’ll describe mild localized hypothermia to the skin, face, or an extremity. Although I’m focusing here on the frozen fingertip or nose, keep in mind that local frostbite can cause serious injury in more extreme cases.

Sizing Up Cold-Weather Danger

Within the category of mild cold injuries, we can divide the various condition into:

• Frostbite
• Frostnip
• Pernio (or chiblains)
• Immersion foot (also known as “trench foot“)

Frostbite can be classified into grades 1 through 4, although you’ll also see a traditional classification that treats frostbite similarly to burns: first degree, second degree, third-degree, and fourth degree.

Frostnip describes mild to minor tissue exposure to cold. It causes tingling and a “pins and needles” feeling (paresthesia) that will improve quickly with rewarming. No permanent tissue injury results.

Pernio (or chilblains) demonstrates ulcers that are reddish, purple lesions, and that can lead to pain and itching. Pernio tends to be most common in young women; however, sex and age is variable. They are treated by relieving the inciting conditions and further cold exposure and by applying ointments, creams, and protective dressings. Pernio ulcers heal over several weeks

Frostbite can be mild, moderate to severe, or classified as grades 1 through 4 in increasing severity. In most mild cases, simple rewarming and protection with a dressing or ointment is all that is necessary.

Considering Frostbite Treatment

In assessing frostbite and determining frostbite treatment, the doctor or clinician needs to rewarm the tissue before he is able to fully diagnose the degree of injury.

Frostbite symptoms typically show up in our extremities (fingers and toes) or exposed areas of skin.

It’s important not to rub or squeeze the frostbitten tissue because this can further traumatize mild injured cells. This is often counter-intuitive because limb-rubbing and friction are often perceived ways of warming exposed extremity or skin.

In mild frostbite (Grade 1), injury is superficial. The area may look pale and there may be some associated redness and slight swelling. In these cases the application of gentle warm air or warm bath emersion is quite helpful, once tissue is fully exposed. The area should be gently cleaned and periodically re-assessed during the warming process. For this type, rapid resolution will occur within 1-2 days.

In second-degree frostbite (early grade 2), one may see the formation of blisters developing within 24 hours (they’re similar to those seen in second degree burns. There may be mild tissue injury or ischemia to soft tissue of the extremities.

In third-degree frostbite, the injury (Grades 3 and 4) is even deeper into the tissue layers, and the blisters tend to be smaller but are associated with bruising and bleeding under the skin. As such, discoloration and scab formation are more common.

Bone amputation is likely in these grades if a digit or small extremity is involved. At this level a surgeon or plastic surgeon and hospital admission is appropriate. There needs to be ongoing wound care in the form of dressing changes and extensive tissue treatment and evaluation. In many cases this severe, a number of minor surgical procedures may be required to remove dead or dying tissue and prevent secondary infection and to control pain and disfigurement.

For the purposes of this discussion I want to stress to the readers that most of you will be dealing with only the most mild exposures (luckily enough) and some very simple rules can help reduce the risk of more serious or advanced frostbite.

The Importance of Being Prepared

In cold weather we can quickly experience frostbite if we are not properly protected and informed as to the risk or changing weather conditions. So, check the weather report. Subzero weather with a wind-chill should be a “red flag” for the donning of warm hats and gloves. If the wind will be persistent (such as in skiing) facial and skin balms that form a protective layer on the skin should be used, in addition to hat, gloves and warm socks. In some scenarios it may be recommended to wear neoprene facial, neck or extremity protection. Any of these wardrobe variations can be readily addressed at your local sporting store, ski shop or camp store.

In the case an exposure the first step is to get out of the cold and then remove cold or wet clothing. After this initial action, rapid re-warming (without flame or direct heat) should be undertaken. A warm bath or shower is very beneficial, as is a properly adjusted hot tub.

Keep in mind that frostbitten tissue may be numb and, therefore, may be susceptible to a thermal burn that is not being felt by the patient, if fire or hot-heat is used to warm the extremity.

Finally, if symptoms readily resolve, a simple dressing of skin salve, ointment (antibiotic ointment, diaper rash ointment, or Vaseline) with a soft sterile gauze dressing is sufficient for full resolution of symptoms over 12-24 hours.

If symptoms persist after the first day, one should follow up with the local Emergency Department or their primary physician for further evaluation, treatment, and possible specialty referral.

If these simple concepts are understood, we can be warm and stay warm and more fully enjoy the benefits in being active in our winters.

HOW TO AVOID FROSTBITE

Do you put nonstop use of your cellphone ahead of sensible protection in the outdoors? (Photo: Saletomic | Dreamstime.com)

Accuweather.com offers these tips on how to protect yourself from frostbite:

• Avoid being in the cold for extended periods of time
• Be aware of the wind chill
• Wear appropriate layers
• Drink warm fluids, but avoid caffeine and alcohol
• Stay active to maintain body heat
• Take frequent breaks from the cold

Various experts also advise that you pay attention to headwear; use a hat (preferably of heavy wool and/or windproof) or a headband that fully covers your ears. Mittens are preferable to gloves; they allow your fingers to draw heat from each other. And your socks and sock liners should fit well and provide insulation; brands that “wick moisture” are preferred—wet feet will get colder more quickly.

See also these posts:

• Frostbite Treatment: Quick—and Smart—Action Required
• Hypothermia: Who’s Most at Risk for This Cold-Weather Danger?
• Hypothermia Symptoms: An ER Doctor’s Tale of a Patient in Dire Shape

The post Frostbite Symptoms: Exposure to the Elements Can Land You in an ER appeared first on University Health News.

Specifically, the patient had a purplish-gray hue to his fingertips and toes (cyanosis), and his torso was cool and somewhat pale. He was only able to mumble, but he appeared to be uninjured and was moving all his extremities aimlessly. Initial exam demonstrated he was intact and uninjured.

Quick vital signs demonstrated a core body temperature of 33.3 degrees C (92 F), blood pressure of 105/62, and a heart rate of about 110 beats per minute. He was confused, lethargic, and cool to the touch.

James M. Bregman, MD, is an Emergency Physician at White Plains Hospital in New York.

Emergency Hypothermia Treatment

We stripped off the patient’s clothes and immediately covered him with heated blankets and wheeled him into one of the warmer Emergency Department rooms. The weather had been cold and damp, and was hovering around freezing with some residual ice and snow present. It was clear that I was dealing with a case of hypothermia in an adult, complicated by alcohol intoxication.

This patient was in serious danger, yet he was only one of many patients on the spectrum of hypothermic injury seen each year in hospitals around the nation. He was obviously ill and in danger, yet my training told me there were certain steps I could take that could quickly mitigate his mortality or further injury.

A Primer on Hypothermia: Diagnosis

Hypothermia is an interesting and complicated condition because it varies, as to degree, along a continuous spectrum of disease, from the mildest cold-induced injury to extremely serious, life-threatening exposure. It is common sense to realize that the human body will become colder the longer it is exposed to a cold environment. It is also common sense to realize that variations in our protection—shelter and clothing—will also make an impact as to how cold we get.

Common-sense advice: Be prepared to handle weather conditions. (Photo © Daveallenphoto | Dreamstime.com)

Mild hypothermia is defined as a body temperature of 32 to 35 C (90 to 95 F), while moderate hypothermia is a core temperature of 28 to 32 C (82 to 90 F). And, finally, severe hypothermia is defined by a core body temperature below 28 C (82 F). These are fluid and rough guidelines, because there are also physiological and individual factors affecting each patient that have an impact on the degree or seriousness of injury.

For example: a patient who is a conditioned runner will have a different clinical response to a core temperature of 32 C. than a sickly or elderly individual with a similar body temperature. The degree of “bounce back” or recovery will vary widely in patients of different states of health, age or body tone.

Core temperature is typically taken the old-fashioned way your mom took it—with a glass thermometer. Rectal temps provide a quick adequate measurement, however, for more seriously cold patients other methods may be necessary, such as an esophageal probe, bladder probe, or intraperitoneal probe. Oral temperatures are not considered adequate to measure the core body temperature.

Reading Hypothermia Symptoms: What They Mean

Not only is there a rough ranking of hypothermia by temperature, but also it is classified “mild, moderate, to severe” by clinical signs and symptoms that roughly follow core body temperature.

The following clinical signs demonstrate some of the ways a person with hypothermia may look should you find them, rescue them, or see them in an emergency setting:

• Mild hypothermia is demonstrated by rapid breathing, dizziness, clumsy speech, impaired judgment and often, shivering. These patients will often be anxious and active on stimulation or examination. They can answer basic questions and will usually be fully oriented and appropriate within minutes of warming.
• With moderate hypothermia, patients will be lethargic and slow-moving. They have lost their shivering response and will usually have a reduced respiratory rate (slow breathing) and a slow heart rate. They will appear sleepy and unfocused. They are often mistaken for being intoxicated or drunk; this is a “pitfall” that any good ER doctor will try not to step in.
• Severe hypothermia is characterized by an unresponsive patient who will have a severely slowing heartbeat and breathing rate. The heart often becomes irregular and will soon stop beating, along with the patient’s breathing and other life functions. The patient will not have measurable vital signs, and his metabolic functions will also cease. At this point, death is inevitable, except in the most extremely rare cases where intervention is rapid, extreme, and highly directed by proper medical care.

Severe hypothermia can occur within hours in most common exposures—or within minutes in very extreme conditions, such as cold water immersion or, for example, on the slopes of Mt. Everest. Falling through an icy lake or being stuck on the side of a mountain in sub-zero weather are not likely scenarios for most people, luckily.

My patient, however, passed out drunk in cold weather—which describes a rather common event, relatively speaking. We live in a society with homelessness and substance abuse, and our weather, wherever we are in the U.S., can be variable. Cold exposure in these types of circumstances can happens in any part of the nation, depending on the time of year.

Hypothermia Symptoms Spark a Quick ER Response

Let’s get back to my patient: His core temperature measured approximately 92 degrees F, which put him in the mild hypothermia group. However, he was not shivering, although he was lethargic and confused.

In this scenario, not only was his alcohol intoxication impairing his response to cold conditions, but it was also blurring my clinical assessment of him and confusing the picture of mild hypothermia. In these types of cases, a good clinician integrates the various factors that create the clinical picture of a patient. In this specific case, it was alcohol intoxication along with prolonged cold exposure.

The obvious plan was apparent, and my team embarked on it most efficiently. “Warm him up” was the first step: We placed him under a Bair Hugger blanket, a device made of soft plastic pumped with heated air.

When placed on the patient, a Bair Hugger provides a continuous warming environment that’s adequate for most cases of mild hypothermia. This method is called an “external warming” technique. By providing a warm environment, we warm the organism and prevent further heat loss. Hot blankets, a warm bath, warm forced air, heating pads, and heating blankets are other external warming techniques.

Treating Hypothermia Symptoms with “Internal Warming”

In more severe cases of hypothermia, clinicians may need to use internal warming techniques. In fact, internal warming is usually required in more critical levels (moderate to severe) of hypothermia. Such techniques are more invasive and sometimes require a procedure or sterile technique. They include:

• Warm intravenous fluids (saline and dextrose)
• Infusion of warm
• Sterile fluids into the bladder
• Rectum or even peritoneal cavity

A patient placed on a ventilator, for example, and ventilated with warm air, is undergoing a form of internal warming. In some severe patients it may be necessary to use warm dialysis fluids or even place the patient on cardiopulmonary bypass machine.

These latter techniques are extreme, but have often been used in extreme cases of cold exposure or cold water immersion accidents. The core temperature in such patients is so low, that there is little ability to generate adequate calories from the metabolic function of the patient.

Even in my cold, lethargic, drunken patient, he is burning calories and creating some fire within, by metabolizing the alcohol he consumed. By keeping him warm for a number of hours, and allowing him to stabilize, he will warm from within.

This is exactly what happened to my accidental visitor. After a fitful night under the Bair Hugger and several liters of warmed intravenous Ringers Lactate solution, he awoke looking for his shoes, and asking for something to eat. He made short work of the ubiquitous dry turkey sandwiches that we always have in the ER fridge. He polished them off, along with several servings of “cup a soup” and a small container of chocolate pudding.

By morning, he was voiding voluminously into the bedside urinal, and soon was walking, however unsteadily, to the bathroom. By morning sign-out, the patient was becoming somewhat of a nuisance, and demanding his rights, his wallet, shoes, clothing, etc. He was significantly oblivious to the resources, energy, and efforts expended to save his life.

A job well-done. So it goes for an Emergency Physician.

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All winter long, as the flu outbreak took hold, people came in tired, anxious, weak, stressed, and feverish. They were scared and required significant supportive care. We gave our patients intravenous fluids, medicine to reduce such flu symptoms as fever and body aches, influenza antiviral treatments, and anti-nausea medication.

James M. Bregman, MD, is an Emergency Physician at White Plains Hospital in New York.

The flu outbreak also meant a heavy expenditure of time and resources. An overloaded medical environment requires clinicians, nurses, technicians, and lab workers as well as custodians, secretaries, orderlies, and others to push the limits of their efforts. It also requires us to work overtime and skip breaks, lunches, and even bathroom stops.

As health workers, we felt the weight of the historic increase in flu patients in 2017-18 by suffering more exhaustion, stress, and ill health. There also was a cumulative “emotional wear and tear.” It is often not emphasized enough how frontline people during such epidemics rise to the occasion while taking it on the chin.

Flu Outbreak Fears

The public has long had its own fears and stresses about flu season, and things only intensified in the winter of 2017-18. People are inundated with anxiety-provoking information day and night on the airwaves and the Internet, in magazines and newspapers, and via smartphones and conversations with other frightened or sickened individuals.

The anxiety over flu symptoms and the threat of germs spreading had people pouring into our ER, scared and in search of cures and protection. They just wanted to feel good again, but wondered if they ever would. They’d even ask if they could die from this flu outbreak.

That sort of fear is prone to exaggeration, hearsay, and misunderstood concepts. The media and the health community, of course, try to make people aware of (and well informed about) pressing health issues. Sometimes, however, other factors—sensational stories and outright misinformation, for example—permeate the conversation. We find this to be true about flu outbreaks and about the spread of germs via bacteria, parasites, and pathogens.

I write this article to address the concerns of the public and to simplify some of the concepts concerning transmissible illnesses, starting with influenza and also getting into other respiratory infections affecting our population.

Influenza Facts and How They Affect Flu Season

Influenza goes back in history to antiquity, as described in many texts from the Far East and in Western culture. For thousands of years, it has regularly infected human populations throughout the world. Influenza thrives in concentrated populations, so as civilization progressed into settlements and cities, the conditions for infectious diseases within human populations were optimized. Until relatively recently, the biologic and genetic mechanisms of influenza transmission were poorly understood.

The modern germ theory was only recently proposed—just over 100 years ago—and demonstrated by Louis Pasteur and Robert Koch, along with others, to the point where we now have a true understanding of germ transmission.

Earlier theories of illnesses included flawed models such as “spontaneous generation” of germs, miasmas, and evil humors. These theories combined religion and magic with early rudimentary science and did not see infectious illness as the invasion of living organisms into a host’s body.

Germs, Germs, Everywhere

We now understand that germs are composed of living organisms or particles we classify as bacteria, protozoa, viruses, and other microbes. Influenza, for example, is a small virus that is now well studied and fairly well understood in terms of its structure and life cycle.

Influenza is an RNA (ribonucleic acid) virus, which means it’s made up of nucleic acid (the genetic code of the virus) surrounded by capsule of protein and sugar-like molecules. Two of the main proteins that are not RNA are neuraminidase and hemagglutinin. They allow the virus to attach, penetrate, and start the machinery for more virus production in the hijacked human cell—typically the cells in the throat, nose, eyes, mouth and other areas.

How Do We Get Influenza?

Influenza is accidentally inhaled and begins an incubation process in the mucous membranes of the unlucky host over one to three days. A patient typically will experience early flu symptoms: a mild sore throat, body aches, headache pain, and chills that usually start abruptly. Patients often say they were well one minute and experiencing flu symptoms the next.

Along with those classic symptoms, you may feel backache, leg pains, extreme fatigue, nausea, eye pain, abdominal pain, and other types of pain or tenderness. The elderly often report only extreme fatigue and weakness, or being unable to rise from bed or unable to walk.

For someone who has a high fever along with nausea or reduced appetite, it’s easy to become quickly dehydrated, further exacerbating the fatigue. In this way, a negative cycle can start—one that will worsen symptoms even further, requiring the sick to seek a bed or medical attention.

In most cases we treat in the Emergency Department, patients require fluid hydration by way of intravenous infusions. This treatment alone is probably the most common and effective therapy that we undertake in the hospital setting. By keeping influenza patients well-hydrated and controlling their fever, we find that patients not only feel better, typically, but that their immune systems are maximized, allowing them to start to fight off the viral infection.

Surviving a Flu Outbreak and Influenza Season

The good news is that the majority of flu victims will quickly get well. Sensible rest—often meaning an extended stay in bed (two to three days, maybe more) allows patients to feel better—no further fevers, improved appetite, more energy, and a reduction in body aches and cough.

So ultimately, influenza imposes, on most of us, a week or more of lost time—no working, recreating, or exercising. A prolonged period of fatigue, sometimes weeks or even several months, is not uncommon. Obviously, it’s important to take the necessary steps to get better and also to set realistic expectations as to your recovery time and normal functioning.

When the Flu Gets Serious

In a rare number of individuals, influenza can lead to severe, life-threatening illness, causing significant morbidity and mortality. The seasonal death toll of influenza certainly has a devastating impact on those individual affected and their families and friends.

The 2017-18 flu outbreak had an overall death rate of only one to five deaths per 100,000 patients. However, if we look only at cases affecting young children (less than 1 year of age) or the elderly (upwards of 74 years old), the percentage of deaths goes up significantly and can be as high as 20 to 30 or more deaths per 100,000 ill.

Flu-related deaths tend to strike the already ill or terminal, but that doesn’t diminish the suffering that these patients endure and the heartbreak and loss that their families endure.

Occasionally, influenza will cause rapid decompensation and death in a perfectly healthy or robust individual. (Decompensation refers to “the failure of an organ—especially the liver or heart—to compensate for the functional overload resulting from disease,” according to Oxford Dictionaries.) This was true for a number of cases in the New York area and in the Southeast in 2017-18 and also in one highly publicized case of a previously healthy 14-year-old female in Ventura County. In all of these cases, it wasn’t entirely understood how such an aggressive and rapid decompensation could occur.

In the infamous influenza pandemic of 1918-1919 (also called “the Spanish Flu”), there was a much higher percentage of mortalities in young, healthy individuals. The death rate during that pandemic was as high as 3 to 4 percent or more and resulted in the deaths of more than 600,000 Americans and an estimated 40 to 50 million people worldwide.

In India alone, the Spanish Flu killed approximately 17 million people. In Iran, the same pandemic killed up to 10 percent of the population. These figures put in perspective the scale and devastating potential of a flu outbreak that spirals into a pandemic.

Is it partly by luck that 2017-18 strain of the flu, Influenza A H3N2, happens not to be as devastating as prior outbreaks and pandemics. Or, have we made a significant impact in terms of early treatment, health, and outbreak containment?

Battling Influenza

The answer to influenza is complicated, but as a medical community, we have improved our understanding of and reaction to those who are sick with the flu. Through computerized databases, we can now quickly track outbreaks and follow the geographic movement of influenza. And we can vaccinate—not completely, but enough to reduce the number of new cases in a vaccinated population. (That point is not disputed or conjecture—as opposed to much misinformation available on the internet.)

We also know how better to support and treat sick individuals who are having complications associated with pneumonia, dehydration, kidney failure, and other problems, allowing them to recover from serious infection more reliably.

We now have, at our disposal, anti-influenza medications (neuraminidase inhibitors) that can slow or delay the progress of the influenza virus in sick patients. Like vaccinations, these drugs are not 100 percent effective. However, there’s significant data showing the efficacy of these drugs. They may be particularly important in the more sick and higher-risk patients exposed to influenza.

Overall, we have a multi-pronged approach to treating flu, and we have a scientific understanding or the biology and epidemiology of its behavior.

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In the warm spring and summer months and other times of year that are unusually warm, we field an abundance of Emergency Room complaints pertaining to various “bug bites.” People come into the ER often sporting a welt, rash, bump, or bite. These are minor complaints, on the scale of ER visits, and pose no real danger in the short term. However, some of these complaints need to be separated from the pack as issues that may require real attention and treatment.

Tick Bite Issues

Bites of any kind are a broad and varied topic that cannot be covered in one article or lecture, so for this post, I will focus on bites from arthropods, or “bugs,” as the lay community calls them—specifically, tick bites.

James M. Bregman, MD, is an Emergency Physician at White Plains Hospital in New York.

The unseasonably mild 2016-17 winter in the Northeast unleashed an abundance of adult ticks who lived through the winter. The result in my area of practice (the New York metro and suburban areas, Westchester, and southern Connecticut): an increased frequency in reported tick bites and associated illnesses, such as Lyme disease, Ehrlichiosis, and Babesiosis.

In fact, these infectious entities are found in many temperate and subtropical areas of the U.S., but the prevalence is highest in the Northeast and upper Midwest. In recent years, more and more ticks carrying Borrelia are found west of the Mississippi. Rocky Mountain Spotted Fever (RMSF) is actually most common in the southeast United States, although initially named for the Rocky Mountains, where it was first described. For the purposes of this discussion, I will concentrate on tick bites themselves and not on the various illnesses that may result.

Digging in on Tick Bite Information

Pictured: A sight that will disgust most of us: an engorged tick, after having fed on its unwary host.
© Ajafoto | Dreamstime

Patients have been signing in to the Emergency Department (ED) this past summer in greater numbers than usual because of the increase in tick populations in my area. A common story is that the patient is in the shower or bathroom when they see a “seed,” or dark spot, hanging off their skin. Often, it’s a spouse or significant other who finds this parasitic hitchhiker.

These patients are often anxious and upset and want some reassurance. Because they have so many questions and concerns, they seek answers at the Emergency Room or in Urgent Care facilities. Clinicians in my area have a depth of experience with such encounters, and have developed a comfortable understanding of initial approach and treatment of tick bites and related illness.

I write this article as a simple discussion of basic facts, gearing it toward the lay population so as to allay anxieties and fears that often accompany tick bites. If you have a concern about a tick bite, I hope this practical information will provide some reassurance, help guide your decision-making, and perhaps allow you to avoid unnecessary testing and treatment.

Is a Tick Bite Dangerous?

Ticks in our area are of the Xiodes Scapularis species (called deer ticks) as well as species of the dog tick variety. They are typically active in warmer months—between March and November—but also at other times in mild weather. Their primary host is the white-tailed deer. Other hosts include mice, birds, rodents, and domestic animals (our own cats and dogs). Any of these creatures can carry ticks close to us, so they fall in our proximity. As such, we can become accidental hosts—and subject to illness.

A tick may then attach itself to us in process of feeding on our blood for its own nourishment. By so doing, the tick completes a life cycle—from nymph stage to juvenile to adult. When a tick feeds, it siphons blood into its digestive system by sucking through a puncture in skin as it holds on via a barbed proboscis and mouth parts (it’s sort of like a straw that hooks on).

The tick feeds for several days and will then drop off, mature to its next stage, eventually mate with other ticks, and complete the cycle when it has offspring.

Is It Necessary to See a Doctor When You Discover a Tick Bite?

There are some common questions and principles that cause concern when people spot a tick or tick bite; I hope I can clarify.

Ideal way to remove a tick: Use tweezers, and pull from as close to the tip of its mouth as possible. See “How to Remove a Tick” sidebar. [Photo: © MorganOliver | Dreamstime]

The first is: “Do I have to go to the ER if I find a tick on me?” The very simple answer is “No!” If you or a friend is comfortable removing a tick with simple forceps, tweezers, or even a credit card, then it’s not necessary to wait hours in an ER. Removing a tick is simple mechanics, and can be done by a non-medical person. (See “How to Remove a Tick” sidebar, below.)

Secondly: “Do I need antibiotics because I was bitten by a tick?” The answer, again, is “No!” Most tick bites will not result in any long-term or acute infection if they are removed within 24 hours.

A given deer tick in the Northeast has approximately a 10 percent chance of carrying the Lyme disease causative agent, Borrelia. In a given tick that has been attached to an individual for one day or less (and that carries Borrelia bacteria), there is a roughly 10 percent chance of Lyme disease transmission. The rough statistics, then, for a given tick bite is 1 in 100 bites results in Lyme disease transmission. For most discovered tick bites that are removed when they are found, there is a very small chance of contracting Lyme disease.

So why, then, is the prevalence of Lyme disease relatively high in Lyme prone regions? The answer is that most cases of Lyme disease are the result of a tick bite that is never discovered. Most people who come down with Lyme disease symptoms are never aware of the attached tick.

Any close look at a deer tick in any stage (nymph, juvenile, or adult) will demonstrate how easy it would be to hide a tick in a body crevasse, hairline, or hard-to-see area. In these cases, the first symptoms often are fever, body aches, headache, and malaise.

In some individuals, the classic “target rash” (Erythema Chronica Migrans) will be visible. This bull’s-eye rash makes the diagnosis easy, and starting medication an easy decision. We are probably fed on by many more ticks—ticks we’re never aware of—than we can imagine.

Tick Bite? Don’t Panic

All of this brings us back to the concept that if we find a tick attached to us, there is no reason to panic. Simply removing it is sufficient. But it does bring up another question: Should we start prophylactic antibiotics? The answer is No!

Recent studies have suggested that taking several doses of antibiotics after a tick bite may lessen the risk of contracting Lyme disease.

Several years ago I was giving one or two doses of doxycycline for a discovered tick bite as a possible prophylaxis. The most recent data, however, suggests that there is no protective benefit in taking several doses of antibiotic for a given bite.

Now the standard of care is to treat Lyme disease with a full course of antibiotics, but to hold off on antibiotics for a tick bite.

In the past, the standard course of Lyme disease treatment was 14 days, but most forward-looking physicians now realize that a minimum of three weeks of treatment is more effective.

Recent data also suggests that 30 or more days of treatment may be most effective for maximum eradication of Borrelia infection, or Lyme disease, and that even a double dose of doxycycline may be necessary to further reduce disease re-occurrence and chronic illness.

Tick-Bite Symptoms?

The final take-home point in this discussion is that tick bites themselves are nothing to panic over and most individuals should be able to treat themselves without visiting an ER or Urgent Care facility.

If you do experience such symptoms as headache, fever, vomiting, body aches, or an abnormal rash after discovering a tick bit, then most definitely seek medical help. The development of associated symptoms as a result of a tick bite could lead to one of the tick-borne illnesses and should be medically addressed. But a tick bite alone does not constitute one of these illnesses and in most cases will not lead to one.

A deeper discussion of the various illnesses that may occasionally occur after a tick bite will be the topic for another day. In the meantime, we can try to rest easy, continue our outdoor activities as usual, and try not to panic should we encounter an attached tick—or, as our patient called it, a “seed.”

The post Tick-Bite Tale from the ER: “Doctor, There’s a Seed Attached to Me!” appeared first on University Health News.

Before these students lies the unscathed landscape of their lives. They will soon confront the successes and failures and all gradations of experience that will come their way. They stand up like a king’s guard in the wake of an oncoming storm, ready to render care and “make the world a better place.” They are the Jedi of their generation’s health providers. They are bright, enthusiastic, and impressive. They will become the providers of compassionate healthcare for baby boomers as we age out.

The Future of Healthcare: Questions Worth Asking

My students eat up my stories and laugh at my overused anecdotes. They absorb my cynical aura and “burned out,” dark vibe, and recycle it back to me in a life-giving nectar. The process allows me to again face the real world—and with a renewed enthusiasm and a realization that things will work out. It will all work out.

This is what I get from them. This is what I take away when I teach a class, and recall those feelings of wonder and hope that I also had many years ago. Years spent in graduate school, medical school, research labs, and residency. Countless nights sleeping in the hospital’s on-call rooms and coming home late, exhausted and tired but inspired. Those nights and days full of “hair-raising cases” and “fly by the seat of your pants” encounters in a city hospital ER. Nights and days spent running to code blues, intubations, resuscitations, discussions with families, humorous and unbelievable stories, anguish, growth, humor, and death all in one day, one week, years compressed into hours.

This energy still lives in me and can be tapped and teased out like an old Texas oil well alive again after a good fracking. This is what my students give to me. What do I give to them? What do we give to them?

I teach their basic sciences and recite case studies and practical information, which will be useful, but what will our society give back to them? What will the medical landscape of the future look like? Will we invest in the care of our weak, poor, retired, of our bankrupt and less fortunate? Will we invest in the future of these young, optimistic, capable individuals? How will we answer these and myriad other healthcare questions of the day?

What type of healthcare system will today’s med students graduate into?

After graduating, they will spread out across our nation, staffing hospitals, offices, nursing homes, urgent cares, and clinics. I know they’ll be able to lance abscesses and treat urinary tract infections, and I am confident they’ll be capable of splinting broken wrists and twisted ankles. They will repair cuts, lumps, and bumps and perform countless dressing changes. They will learn and grow, as I did, and suffer the humbling blows of medicines’ unforeseen surprises and “blind-side” events. This is what I give them, but what do we leave them? What will their medical system look like? I am truly uncertain—and deeply concerned.

America’s Concerns for Healthcare: Questions Outweigh Answers

In the wake of the 2016 Presidential election and subsequent inauguration, I have fielded numerous healthcare questions from my students, who—as I have observed during our discussions—are rife with fear, anxiety, and uncertainty.

They ask me, “Hey Doc, how will healthcare change if the Affordable Care Act [ACA] is repealed?” They ask, “Will there be a place for us?” “Why would any right-minded politician want to dismantle health coverage?” They ask me if I think that hiring in clinics and reimbursements in health facilities will change.

They also convey a sense of dismay and disappointment in my generation. Why did we let them down? Why did we let us all down? They express to me, “Who on earth would vote so vehemently against their own interests? What is the problem with your generation?”

After the election, their enthusiasm and hope turned, overnight, to anxiety, fear, and frustration, much of it directed at the baby boomers and institutions who were supposed to uphold a higher standard. They now scoff at the foundations of a nation that once claimed to be something different than what it seems to be now.

ACA Repeal: What Does It Mean?

As I write this piece, I just watched on the news that our esteemed POTUS signed an executive order to start the repeal of the Affordable Care Act (a.k.a., Obama Care). I am flabbergasted that some of us thought that caring (i.e., Obamacare) was a bad word. Since when did caring put us at a disadvantage?

The train is now rolling, and it looks like the repeal process is in motion. Is there another plan to provide care and cover our citizens? Not sure. Will there be provisions to keep the aspects of the ACA that all of us actually wanted? Not sure—not even a vague idea, because no definitive plan has been put forth. Will we cover people with pre-existing conditions? Do we get to cover our children on our own plans until they’re age 26?

In these post-2016-election days, healthcare questions are a major concern for Americans. Repealing the Affordable Care Act (a.k.a. Obama Care) is one thing; replacing it is another, and, as our blogger notes, the new administration hasn’t accompanied its repeal efforts with a replacement.

None of this is known, but what is more frightening is the assumption on the new administration’s part that everything about the ACA is bad, and the only one who can give us a good plan, an affordable plan, a quality plan, is our POTUS—even though he has never put forth any viable plan with any details, and hasn’t shown an understanding of the complexity of a healthcare system.

I don’t want to criticize or disparage those who helped put our current POTUS in office, but I hope they are at least partly aware that health coverage is at risk for a number of people. I hope they realize when they go to their churches and temples and places of worship to reflect on the best of humanity that this incoming administration may be responsible for making some lives more challenging.

An example would be the ACA’s “Black Lung” coverage for coal miners and industrial laborers. The new administration has every intention of cutting this coverage. The most extreme members of Congress look at as an unnecessary expense or even an entitlement program. The administration gives me the impression that it would rather build another destroyer then worry about the pulmonary disease of so many who made the company owners rich.

This attitude by our new leaders to politicize a system (however imperfect) smacks of immoral if not at least deeply cynical. The move to dismantle a system that protects many Americans before elucidating any new plan to take its place is exactly what is happening now.

These are the facts I use to answer the hard questions put to me by my students. I have to explain to them that our generation wants them to perform their best, be their best, and think their best even as we clumsily slash away at the support structure of our own citizens.

We ask these students to rise to a higher standard, but will we continue to take care of the weak and less fortunate? I am ashamed of our generation in this respect, and disappointed that we dishonor the legacy of my father’s generation with what I see as a backward-moving force in ACA repeal. I feel as though we have become what we once feared. In some ways, the hate groups, fear mongers, and terrorists have won the day.

Healthcare Questions May Weigh on Us, But… Don’t Give Up

Our world has seen unbelievable turns in the years since I was starting a medical career. Look at what has gone on during the past few decades. Could we have imagined any of the odd, fantastic, sometimes humorous, often dark events that have dotted the timeline of the late 20th and early 21st centuries?

In the minds of at least half of all Americans, the promise of “hope and change” has been replaced by negativism, suspicion, and pettiness in the highest office in the land. We’re better than that… aren’t we? This is our world and we must make of it what we can—and try to create a world of respect, truth, and fairness.

I want to tell this to my students. I want to be able to say that the universal arc does bend positively, and there is no shame in helping the “little guy,” the “different guy,” the “other” or less fortunate (even if there is an economic cost). I want to be able to say these things, but I am not certain that I honestly can, given the current stance of the new government and its cynical characterization of our national condition.

Now is not a time to look inward and embrace suspicion and fear. Now is not a time to look away from science and creativity. We should embrace progressive ideas and help each other move forward in this incredible world with its unlimited possibilities. We should embrace the same optimism and hope that my students impart on me when I teach them. This would be the greatest gift we could give to their generation.

Originally published in February 2017 and updated.

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