All posts by doctorswithoutwaitingrooms

EMPOWERING PATIENTS THROUGH EDUCATION AND TELEMEDICINE

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #1 – THE “CHRONIC COUGH”

In my 88 years, I have had at least a dozen medical problems. Some have gone away on their own, some have been removed surgically, and a few have become CHRONIC, lasting for years, ultimately becoming a part of my life.

I have compiled a list of these and other SYMPTOMS & CONDITIONS I have seen as a physician. Over the next year, I will discuss them one by one, appending these vetted articles for further reading.

The ‘CHRONIC COUGH’ will be the first discussed.

As an Allergist, I was involved with coughing all of my adult life. If my patients did NOT have asthma, they usually coughed from mucus pouring down the back of their throat (post-nasal drip), from their allergic nasal condition (allergic rhinitis), or sometimes from the associated SINUSITIS drainage.

Asthma was a much more common cause of Chronic Cough for my Patients, sometimes theIr main problem. All asthmatic have a chronic inflammation of their breathing tubes(bronchi), and the resulting BRONCHITIS irritates the airway nerve endings, causing Cough.

Without enough narrowing of the airways to cause wheezing, this is called “cough equivalent asthma”. With the addition of airway narrowing (constriction) to the above situation, ASTHMA results.

There is added shortness of breath (dyspnea), and the cough becomes the “tight” wheezy cough of full-blown Asthma.

COPD (chronic obstructive pulmonary disease) may be a residue of long-term asthma, but commonly results from cigarette  smoking. Where loss of alveolae (air sacs) predominates, dyspnea (shortness of breath) is more common.

Where bronchial tube inflammation is more prominent, mucus and cough result. This cough is useful in clearing the mucus; a USEFUL COUGH (although my Patients did not always appreciate their friend, which could be bad enough to cause hernias or incontinence). 

Gastro-esophageal reflux is a chronic condition where stomach contents are not retained in the stomach by the G-E Sphincter ( a type of “purse-string” Gate), but spill(reflux) up, when not restrained by gravity, at NIGHT. The ACIDIC STOMACH CONTENTS burn the esophagus on the way up(heart burn), and are often aspirated into the airways during sleep, causing inflammation and COUGH.

There are many other less common CHRONIC LUNG ( pulmonary) DISEASES (conditions) such as sarcoidosis, bronchiectasis, interstitial pneumonitis, TB, and cancer, that can be diagnosed by imaging (X-Ray, etc.). Heart failure can also cause cough, as can blood pressure medication (ACE inhibitors). 

Smoking is an obvious cause; chronic smoking, chronic cough. Smokers know what is causing their cough, and usually don’t bother coming to the Doctor unless they cough up some blood, or develop one of the myriads of diseases caused by their habit.

If you have a chronic cough, check with your Primary Care Doctor, who may refer you to an Allergist or Pulmonologist. The following article will be useful to your understanding of cough, and will provide a LIST OF QUESTIONS the DOCTOR will likely ask you.

—Dr. C.

Further reading #1

Further reading #2

VIDEO: “IS TELEMEDICINE THE FUTURE OF HEALTH CARE?”

The coronavirus pandemic has overwhelmed hospitals, physicians and the medical community. That’s pushed telemedicine into the hands of providers and patients as the first response for primary care. Telemedicine isn’t new to the medical community, however it hasn’t been embraced due to insurance coverage, mindset and stigma. Here’s how it works and what it means for the future of health care.

COMMENTARY

The safety and convenience of Telemedicine have been amply illustrated by Covid 19. It’s place in the future of Medicine would seem to be assured.

Once the epidemic is over, however, some sticky details, waved away by fiat during the early days, must be addressed.

Will Payment parity be allowed by the Health insurance companies (And Medicare) be continued? Will cross-border Practice still be allowed by the states. Will more Doctors modernize? Will lawyers (and litigious patients) restrain themselves?
Stay Tuned!

—Dr. C.

OPINION: HEART AND BRAIN HEALTH ARE LINKED FOR LIFE

Your heart and your brain are your two most vital organs, and if you enjoy life, they should be a top priority. These amazing structures are tethered to life-giving support by your arteries, just as the new you was tethered by your ubilical cord.

Life is fragile, hanging by a thread, or an artery. over the span of your life, These arteries can become plugged by fatty deposits called plaques. A healthy life style-SLEEP, DIET and EXERCISE– could slow down or prevent this atherosclerosis.

But everybody should know about the symptoms of HEART ATTACK and STROKE (1) and how to respond if the arteries sustaining your heart or brain become blocked.

You should be familiar with the hospitals in your area. How close are they? What are their capabilities? Are they Class 1 for heart attacks and stroke? Do they have a CATH LAB?

SPEED is important. Within minutes of the BLOCKAGE of an ARTERY to your heart or brain, vital cells start to die. The goal is to remove the blockage as soon as possible. CALL 911 as soon as you have heart attack or stroke symptoms. Don’t be afraid of the ER because of Covid, since almost all now use TELEMEDICINE SCREENING to keep infected patients segregated.

Alas, for many people, such PREVENTATIVE MEDICINE requires too much SELF DISCIPLINE AND CONVICTION. America has an epidemic of OBESITY and an avalanche of tasty FAST FOODS provided by a CONSUMER SOCIETY that is ever-attentive to the latest fads and trends.

DR. C

DOCTORS CALL: “CHRONIC COUGH – DIAGNOSIS AND TREATMENT” (MAYO CLINIC)

On the Mayo Clinic Radio program, Dr. Kaiser Lim, a Mayo Clinic pulmonary and critical care physician, explains chronic cough and how it can be treated.

Read more

COMMENTARY

If you have had a cough for more than 8 weeks, the good news is that you don’t have Covid 19. The bad news is that you need a Medical evaluation, tests and imaging to find out what is going on.

COUGH is not a disease, but is a manifestation, a SYMPTOM of a disease.

Your Primary Care Doctor will do a Medical History, an examination and a chest X-Ray which may allow her to DIAGNOSE what disease or problem Is causing the cough, and allow her to treat it.

If you continue to cough, you will be referred to a specialist, such as an Allergist or a Pulmonologist. ENT (sinusitis) and Gastroenterology (GERD) are 2 other medical fields often involved.

Usually blessed relief comes when Chronic Cough is properly diagnosed and treated, but a few Patients continue to suffer, challenging the best of medical care. 2 of my friends continue to cough after Medical School Level evaluations.

Nature continues to hide some of her secrets from Medical Science.

—Dr. C.

TELEMEDICINE 2020: guidance to move forward in a POST-PANDEMIC world

From a John Locke Foundation article (May 13, 2020):

A combination of stay-at-home orders, recommendations from health professionals, and the rollback of restrictive telehealth regulations boosted the use of telehealth.

….with an eye toward the future, the authors offer recommendations for all interested parties to consider moving forward. These recommendations were informed by our research and a stakeholder meeting of industry groups who work with telehealth. These groups included Doctor on Demand, the American Medical Association, and the Center for Connected Health Policy. The paper’s recommendations are as follows:

  1. Data on COVID-19 telehealth administration and programs must be collected and analyzed.
  2. Regulatory flexibility should be built into telehealth to accommodate the range of use cases.
  3. Telehealth services should be utilized for primary care to reduce service redundancies.
  4. States should be empowered to move away from parity models to reduce the cost of telehealth services.
  5. Telehealth services should be available to the medically underserved.
  6. Innovation, privacy, and data security in telehealth services should be the norm.

Read more

COMMENTARY

Telemedicine  is an “almost perfect” extension of Medical Care for the Covid epidemic (1). As we ease away from Panic, we will not be abandoning distancing, cleanliness, and other personal measures that keep us well. SARS-CoV-2, or the next Pandemic Virus will be lurking in the background. 

Likewise, Medicine will always embrace Telemedicine for its’ convenience, safety, and efficiency, if we can overcome the roadblocks discussed in the above article.

One efficiency in particular, discussed in the previous RPA( from Australia) article stood out; the use of Nurse-triage to direct telephone (or someday audio-visual) Patients to the most appropriate destination; ER, Urgent Care, after-hours clinic, or home care.

The Schmidtt-Thompson protocol ( which guides triage) has been used since 1980, having stood the test of time and lawyers. It is available in electronic form, and when fully automated, it should be made available without cost.

Just imagine all of the unnecessary ER visits And Physician Visits potentially saved!

Telemedicine has indeed added convenience and safety in the Era ( it seems like forever) of Covid.

There are many Telemedicine ideas that will still be used when Covid hopefully  takes its’ place in the Influenza immunization vial.

—Dr. C.

TELEHEALTH IN AUSTRALIA: “RPA VIRTUAL HOSPITAL” IS A 24/7 PATIENT CARE SYSTEM

From The Guardian (May 12, 2020):

“Now, everybody is on board,” says Dr Teresa Anderson, chief executive of the Sydney Local Health District. “There is not one clinical department across the district that is not providing care virtually.”

hat

What a difference a pandemic makes. Although RPA Virtual Hospital was well into development when news broke from Wuhan in January, pandemic preparations meant it was scaled up far quicker than had been envisaged.

Anderson says RPA Virtual Hospital opened on 3 February with just six nurses. It now has more than 30 nurses, as well as medical and allied health teams, and 600 registered patients. Operating out of Royal Prince Alfred Hospital campus, it functions in many ways like a regular hospital, with a clinical handover, ward rounds, multidisciplinary team meetings and its own governance structures.

The virtual hospital is part of a wider suite of innovations developed at breakneck speed during the pandemic response, which include providing care in rented hotel and apartment accommodation to Covid-19 patients and others in quarantine, thus freeing up hospital beds.

Read more

COMMENTARY

The Covid epidemic spurred development of an addition to an already good medical care system.

A group of chronically ill patients were invited into the virtual care system. Nurses are used on initial encounter. They direct the enhanced home care, referrals or hospital care as needed. Electronic devices record the care given.

Hotels are used to quarantine suspected Covid patients, with telemonitoring.

As in America, the Covid epidemic has exposed the excesses of unneeded “elective” surgery, most notoriously surgery for back pain.
We can learn a lot by studying the health care of other countries.

—Dr. C.

TELEMEDICINE BENEFITS: PATIENT’S “CONVENIENCE & SAFETY” TOP THE LIST

From a Permanente.org online article (May 11, 2020):

“Our patients are glad we offer telehealth options because they don’t want to come to the medical centers. This allows them to stay home and stay safe,” Dr. Lee says. “Before, telehealth was a choice and convenience, but now it’s one of the ways patients remain healthy with social distancing.”

The majority of telehealth visits are phone appointments, but Dr. Lee says video usage is increasing as more patients become comfortable with the platform.

Telehealth can also include services such as remote patient monitoring, which allows patients to take blood pressure measurements and blood sugar readings at home so that their care teams can monitor ongoing health conditions. In the case of the Kaiser Permanente Mid-Atlantic States region, doctors also use telehealth to do rounds virtually for patients who have suspected or confirmed COVID-19.

Patients at higher risk for complications are given pulse oximeters so their doctor can monitor for signs of severe respiratory infection before other symptoms might indicate a need for additional care, including hospitalization.

COMMENTARY

TELEHEALTH is HERE TO STAY. It came in with the telephone, and has been gaining in recent decades. The distancing and Patient convenience so characteristic of Telehealth made it a natural fit for Covid 19, which has accelerated its’ adoption.

Your CLINICAL HISTORY, led by the Story of your Present Illness, has since time immemorial been the MOST IMPORTANT ELEMENT leading to accurate  DIAGNOSIS. During a TELEMEDICINE VISIT, your doctor must make the MOST out of your clinical history. She can’t do a proper Physical Exam, although she can usually see you, and maybe direct a SELF exam. Teledata, such as EKG,B.P., and blood sugar will become increasingly available.

Your Doctor can usually get enough information to order Lab work and Imaging; and prolix ordering can be tempered, since a good HISTORY of the PRESENT ILLNESS, systems review, past and family history can narrow the diagnostic possibilities considerably. The pressure of time and demanding computer Records may lead the overworked Doctor to use Lab Tests to make up for insufficient Medical History.

Integrated medical systems, such as Kaiser, can also easily access your past medical information, one of the advantages of having everything under one roof.

Informed Patients, SELF-EDUCATING themselves from the vast trove of medical information on the internet (and maybe DWWR) can author their own MEDICAL NARRATIVE, or at least make the Doctors job easier.

—Dr. C.

Read full article

HEALTH: “HOW THE BODY CLEARS COVID-19” (VIDEO)

Understanding how the body clears the new coronavirus is becoming more important as the U.S. begins to reopen. WSJ’s Daniela Hernandez explains how the body fights infection and why feeling better doesn’t equal being virus-free. Photo illustration: Laura Kammermann

COMMENTARY

This excellent video is well worth watching and listening to. It revisits how the immune system, both innate and adaptive responds to SARS CoV and other viruses.

It shows graphically how long the body takes to clear the the Covid 19 virus.

And it makes me, a susceptible 88 year old, even more alert to infection. We should keep our guards up.

Even if an effective vaccine is found, it will probably take its place, incorporated into influenza vaccine as an annual immunization.

Dr. C.

OPINION: “HIGH ANXIETY IN THE TIME OF COVID-19”

Develop interest in life as you see it; in people, things, literature, music – the world is so rich, simply throbbing with rich treasures, beautiful souls and interesting people. FORGET YOURSELF.

Henry Miller

Individualism and authenticity are highly valued traits in a free democratic society. My own concepts of American ideals canonize the  associated freedom. But there is never a “free lunch” in the realm of human nature.

Roy F. Baumeister’s  Book, “Escaping The Self” (which I read a couple of decades ago and either loaned out or lost) started me thinking about the BURDEN OF SELFHOOD. I recently listened to a BBC podcast on the Philosophy of Authenticity (BBC Radio 4 – In Our Time has upwards of 1000 forty-five-minute programs on topics I recommend highly). They discussed the  plight of the “Existential Hero”, and rekindled my interest in the over-demanding Self,  which idea I will argue can help guide an approach to ANXIETY.

Cooped in by SARS CoV-2, the U.S. has experienced a sharp rise in Anxiety and Depression. The Pandemic has deprived us of the sociability, diversions and travel that had previously lured us outside ourselves, and our jobs (except for the computer-connected) which give us purpose. The connectivity (and self-abnegation preached) in religious services has long been on the wane in secular America, and Covid 19 has temporarily closed the remaining Houses of Worship.

How does the Idea of getting OUTSIDE OURSELVES help the person in the grips of Anxiety? If nothing else, it serves as an organizing principle for the CHANGES IN BEHAVIOR (eg. CBT) necessary for lessening Anxiety. Changes in behavior are necessary; you cannot merely will Anxiety away.

IMAGINE the self as an expensive over-large HOUSE. It’s construction started at the moment of your birth, and progressed through infancy (perhaps with a few defects- we can always blame our parents – i.e. attachment theory). It was damaged by Adolescence, improved by our education and occupation, and remodeling continues our entire lives.

Being restricted to our homes is like Solitary Confinement. Having only our own minds to keep us company is severe punishment for 99% of humanity. What would you do if deprived of the internet and confined to a mountain cabin for just one day?  We are used to pervasive and instant connectivity. Our norms of isolation now would have been considered quite expansive just a generation ago. Well, maybe practice living with ourselves is a benefit of Covid – that which does not kill us, etc…

Using the house analogy, we spend a lot of Money and effort decorating the outside of the house  to impress our neighbors (‘amor propre’ of Rousseau). Spending time on Facebook rather than improving the inside, via  re-framing and behavioral change. The many rooms of the house also suggests the many compartments of the mind, some of which are more accessible than others, some almost unknown.

The analogy is far from perfect. For one thing our house should have legs to let us, the little person inside (the ‘homunculus’ of consciousness metaphor), walk our expensive and beloved (I hope) house through the world. Or better yet, ESCAPE IT BY OUTWARD FOCUS.

The ‘yourself-embracing reality’, out in the world, without the distortions (and protections) of your carefully crafted identity.

Do you dare?

Service (work) gets you outside yourself. To quote Kant:

“I slept and dreamt that life that life was joy. I awoke and saw that life was service. I acted, and behold, service was joy.”

Mindfulness (meditation) gets you outside yourself, to focus on the outside world. The religions of the world prescribe much of our behavior, defining our self-importance, and our expensive houses as “pride”, as something to diminish.

The word Ecstasy (not the recreational drug) is from the Greek (“to step outside oneself”). Ecstasy ( as well as orgasm, i.e. Woody Allen) may be OK occasionally, but for every day, most of us would prefer the Delphic Oracle admonition: “Medan agan (μηδὲν ἄγαν) – “Nothing in Excess”.

Enough hot air already! For those who prefer practical tips or neurobiology to conceptual framework, see the articles below.

-Dr. C.

Article #1

Article #2