Digging Deeper

**In not finding the toy he was looking for, he threw his hands up in the air.**


"Drat!" I thought. Because when I looked next to the patient's lab result, I was hoping to see a yellow triangle that would indicate that something on the labwork was flagged as abnormal. But I saw nothing. And while I generally hope for good news and clean reports, sometimes I am looking for something to explain the situation. I am looking for the answer. And no yellow triangle means no easy answer.

When the symptoms are particularly nebulous, and the question of where to go next is somewhat daunting, it is easy to want to give up. To say, "Well, your blood work looks fine." The end. But, of course, you can't do that.

So, we wait, my patients and I, to see how the problem evolves. We keep digging. We 'monitor symptoms.' I re-examine them. I ask more questions. I ask specialists for their opinions. We re-check the blood, looking for other possibilities.

And usually, one of two things happens:

1)The problem resolves itself. Tincture of time, or change of situation, or the body just healing itself.

2)Our further investigation yields the result. And the harder it was to find, the more satisfying it is to fix. Or to understand. Or what-have-you.

And I think the same type of thing happens in life outside the doctor's office. Sometimes there is a problem we can't quite put our finger on, but something feels off: a relationship, a child, or a mood. And upon our initial scan of possible root causes, nothing obvious comes up.

It is tempting, I think, to say, 'well, whatever. I guess we just aren't clicking.' Or, 'I guess I'm just feeling off.' Or, 'I guess my kid is just in a phase.' But I've learned that it is worth it to press on in our search to understand why we are feeling how we are, or why we are relating to others the way we are, so we can heal those relationships and heal those parts of ourselves.

Because even just the exercise of looking for solutions, shows that you think the cause is worthy of your time and concern. And just as a patient appreciates when I don't brush them off when their issues have become difficult to understand, those we love do too.

Sometimes, I think, just taking that time to understand is what opens up the way for things to heal themselves. But other times we ultimately stumbles across that yellow triangle, and with a sigh of relief and satisfaction, set about fixing the problem.

*If you are getting frustrated in your quest for answers, try a little pit-stop for Mickey Mouse Pancakes. They do wonders in our household.**


P.S. I love this talk on healing given by a former dean of nursing.

This and That

**This smile is one I rarely see in front of the camera from Tiny. Normally she srunches her eyes nearly closed. Apparently it takes my fabulous BFF, Nancy, to bring it out in her. Which means, clearly, that Nancy will have to be in all of our family photos from now on. Too bad she takes most of them. :)



**That concert was amazing. Seriously, if you haven't heard of "The Avett Brother", check them out. They move my soul. Rockstar laughs when I say this, but there is no irony in my voice!

**Does this phase look familiar to anyone else? Experiments in gravity!!







**This article certainly warrants consideration. I've long tried to avoid holding my cell phone close to my head, despite no consensus in the research about whether this is dangerous. This study quantified that something is happening, even if we don't know yet quite what. Part of why we keep our landline is so that we don't always have to use our cell phones for longer conversations at home. Until we know for sure what we're dealing with, it doesn't hurt to take precautions.

**That Rockstar is such a good breakfast-maker. If we have extra bread from dinner (like the whole wheat sourdough from last night), Rockstar likes to turn it into french toast instead of letting it turn to a too-hard-to-use waste.



**This one friend of mine gave me a great tip. She puts whipped cream on her kids' french toast or pancakes instead of syrup. It has way less sugar than syrup and seems just as exciting. We prefer to layer peanut butter, applesauce, and whipped cream.




**That kind of exuberance is what I want to aim for next week. And, you know, just in general.



**This face melts me into a puddle. And if you are wondering why most of my pictures of Lil' Drummer take place in his highchair, it might be because that's the only time he sits still long enough for me to snap a decent one. :)



Happy Weekend!

Decisions, Decisions

"Please, Mom?"



Every mom has to make choices about how she uses her time. Because I work as a physician part-time, I have to give some of my time to work. So I try to be very intentional about giving my non-work time to my kiddos. I try not to multi-task. That generally works out quite well. But on the day where I only work in the afternoon, it can get a little dicey. The specter of the afternoon's work is always in the background, and while I usually ignore it until it's time to go-be-a-doctor, that can be hard.

I like to keep a handle on my 'tasks' (our version of an inbox...which gets filled with lab results, consult letters, prescription requests and patient messages) because I'm a little OCD that way. So this morning after our breakfast routine was through, while Lil Drummer was down for a nap, and Tiny Dancer was playing downstairs, I surveyed my time. I wanted to play with Tiny for a while, then take her on a 'mommy-daughter' date. Because the babysitter can stay with Lil Drummer while he sleeps, this is great little time for us. I love that as long as a trip to the library or lunch out is tacked on the end, she doesn't mind if our dates include Target, Trader Joe's or other errands. Today I was aiming for Target and TJ's as part of our date.

But then I logged onto the our work system. "Just really quick!" I thought, "I'll complete a few tasks, and then we'll head out." I don't like showing up to work and finding that my cup runneth over with messages.

And what's that law Murphy wrote? Cause there were a lot of tasks to be dealt with. So I did. Time kept ticking away, and E was playing on the floor next to me. 'Just a few more.' Then we were down to enough time for TJ's but no Target. 'Just a few more.' And then it was down to a quick stop at the library. 'Just a few more.' And then it was, 'My tasks are finally done, but I should really leave for work in 25 minutes.' Which doesn't leave room for much of anything at all.

I closed up my computer and she looked up at me. "Are we ready for our mommy-daughter date now?" Oh, the look of anticipation on her face!

In that moment, I made up my mind. "Yes, we're ready. C'mon, let's get in the car!"

"Can we got to the Library, then Target, then Trader Joes?"

"Um, I think we just have time for lunch. Is that okay?"

She smiled. "Yeah, that's okay."

We dashed to a nearby Starbucks where we split a panini and a bagel with cream cheese. She told me about her Primary lessons last Sunday, observed our fellow cafe-goers, and insisted on spreading the cream cheese all by herself.

When my clock read only a minute or two until I had to leave for work, I handed her the last bit of her bagel to carry, and we walked hand in hand back to the car. I dropped her off at home, where she gave me a kiss and told me to 'be safe' on the way to work.

I made it on time. By the skin of my teeth.

And as I drove, I thought about how there will never be enough time. With more than one kid, or with a job and a kid, or with any amount of demands on your time, it will feel like there is never the ability to give everyone their due.

But maybe I need to re-think what is enough.

Because for today, a stolen moment at a starbucks table, making up silly stories over a bagel and cream cheese, seemed like enough time.

Like just the right amount of time.

Office Talk: Over-the-Counter pain medicines

Question: So, I know I'm not supposed to take too much Tylenol, right? It's gonna kill my kidneys.

This is an area in which I see a lot of confusion. Many patients have a vague sense that Tylenol and Motrin can cause problems, but more than half the time, they are mixing up which is which. Since taking these medicines unsafely or indiscriminately can have serious consequences, and since the fact that they are OTC can lull people into a false sense of security, I figured I'd clear this up.

1)Tylenol (a.k.a. Acetaminophen)



Tylenol is a great medicine, and very safe when used properly. It can reduce fever and pain. It's safe in babies and pregnant women. It isn't the strongest pain reliever in the world, but it works. What makes Tylenol so great is that if taken in proper doses (no more than 4 grams in a 24 hour period), it's something that can be taken daily for a long time (years even...which some of my patients with arthritis do). It doesn't have a cumulative damaging effect on the liver over time, assuming you have a normal, functioning liver. The danger? It doesn't take much extra Tylenol to cause a serious overdose. It seems like such a harmless drug, that some people figure popping a few extra at at time won't hurt. But if you look at the graphs of how easily you can get into the danger zone, there isn't a lot of room for error. So stick to the doses as prescribed on the bottle. If you need more pain relief? Try a different type of drug. And remember that 'acetaminophen' is a common ingredient in most cold/cough formulations and even narcotic painkillers. So check for that, and don't double up!


2)Ibuprofen (Which belongs to the NSAID class of medicines. This includes motrin, advil, aleve, naprosyn).



Ibuprofen can also reduce pain and fever. It does have some anti-inflammatory properties, though we as physicians tend to overstate the anti-inflammatory effects. It's anti-inflammatory effects can be quite useful for sore throats, period cramps, and acute tendonitis/bursitis. For many people, the pain relief they get from NSAIDS is more potent than that which they get from Tylenol. I know that's how I feel (which is why I miss it so much when I'm pregnant!) And unlike Tylenol, it's probably fine to take a few extra than what it says to on the bottle. In fact, we frequently prescribe such doses for severe pain. And it's a lot harder to overdose with these medicines (thought it is possible). The real problem is when people start taking them on a regular basis over weeks, months, or years. That's when you run into erosion of the stomach lining (and possible bleeding ulcers), kidney dysfunction (which thereby increases blood pressure), and increased risk of bleeding in general. I actually had a patient while I was a resident who was on dialysis from prolonged, heavy use of NSAIDS. So, they are great short-term meds, but poor long-term ones.

So, to recap:
Tylenol: good for long-term use if used in proper doses. Affects the liver.
Motrin: okay to increase the dose in the short-term. Hard on the stomach and kidneys long-term.

Consider yourself informed! :)

Shhhh...It's a Secret

**Weekend Happenings: Waffles and Sticker Books. Rockstar and Tiny Dancer like to make breakfast together. I like to benefit from the tradition.**

Do you remember that book 'The Secret'? I heard about it on the radio, back when Oprah was going to discuss it on her show. From what I understand, the basic premise is that you send out a wish into the Universe for something you want(a soulmate, a million dollars), and somehow by desiring it, wishing for it, picturing it, it will come to you.

As 'power of positive thinking' as I am, this seems rather hocus pocus-ey. However. I have my own medical version of 'The Secret' going. It goes something like this:

Randomly one day while I was a resident, it occurred to me that I hadn't done an anoscopy in a while. And if you are green with envy at the thought that I get to do anoscopies, I totally understand. But I'm funny like that, and not much grosses me out anymore.

So when within a day or two of thinking that, a patient with hemorrhoids was on my schedule, and needed an anoscopy, I thought, "Huh. How funny...I was just thinking about that!"

And then it happened again and again and again.

"Gee, I haven't had to remove a toenail in a while."
"Hmm...I haven't had to admit someone to the hospital from the office recently."

Poof! A toenail removal. Poof! A hospital admission. etc., etc.,

So last week, as I was sitting there in my office, just letting my mind wander, there came one of those thoughts, "Huh...I haven't had to do stitches in a while."

I don't have to tell you where this is going.

I was working the Saturday morning "acute care" clinic this last weekend. And when I saw on the schedule that someone was coming in with a cut finger, possibly requiring stitches, I knew which doctor(me) would end up getting to see that patient. When I say 'getting to see', I mean that. My colleagues and I all enjoy procedures.

Sure enough, I was the next doc up for a patient when the injured hand was ready to be seen.

I took a look at the cut and said, "Yup, we're going to need to stitch this."

I gathered my needle and thread, and set about closing up the wound. (Incidentally, as I was tying my knots, I thought, 'Who says I'm not crafty?!?' A different medium, perhaps...)

The difference between me and 'The Secret', I suppose, is the fact that I'm not being intentional about it. So maybe I should change that? Maybe when I'm craving the chance to do a biopsy, an IUD placement, or a certain medical work-up, I should send that wish that out into the universe and see what ends up on my schedule.

On second thought, I'd probably be better served trying this on my kiddos. i.e., "I'm visualizing a toddler who always shares with her baby brother." "I'm wishing for a baby who never wakes up teething."

Ha! I doubt it works if you can't even do it with a straight face. Cause I don't think I can. "The Secret: Medical Version" notwithstanding. :)

**What about you...do you ever have any 'The Secret' moments?**

This and That

*This is what the inside of my brain feels like for a few months after I have a baby:





It takes a while to clear out spaces amongst all the thoughts and between all the fatigue that come swirling in with a new person (as it obviously takes me a while to surface from the hurricane of the morning routine and breakfast dishes). So when I went back to work when Lil' Drummer was 3 months old, you can understand that this was still a work in progress. Come to think of it, it still is. But I need an excuse for the following anecdote, as you will see.

A 3rd year medical student was shadowing me one morning. And running on a little sleep, I kept forgetting to grab my stethoscope off the nurses station before I went into a room. So as we'd go to examine a patient, I'd exclaim to the medical student, "Oh! I keep forgetting my stethoscope. Can I borrow yours?" "Sure," he'd say, and hand it over. This went on for 2 or 3 patient's. Finally, while we were standing outside of a room, he said to me, "You know, you're welcome to keep using my stethoscope, but yours is right there. In your pocket."

I looked down and sure enough, the stethoscope that I kept claiming not have, was sitting right there.

"Oh, right!" I said. And trying not to blush, I also decided not to think of what my patient's thought of my borrowing another stethoscope when mine was so obviously available. Maybe they thought it was some other piece of medical equipment sticking out of my pocket? One can only hope.


*That Lil' Drummer has required a lot of this today:


His teeth are bugging him and causing us to have a few nighttime interruptions the last few nights. But you know what? There's still no one I'd rather share a few cheerios with:







*This Valentine's Day Banner (or something akin to a banner...Tiny Dancer and I lost steam when it came to connecting our paper our hearts) makes my mantle so cheery. I'd like those hearts and those Tulips up for months. Can we pretend it's still 'Valentine's Day Season'?







*That party was rockin'. Too bad no one was invited except for me. The chef is divine--she serves innovative combinations like raw onion and green apple. Maple syrup is the key ingredient in everything.




*This article is a wake-up call for parents. It's really scary to hear how many crib related accidents and deaths there are. I know we'll be checking ours to make sure it's safe, and lowering it in an attempt keep Lil' Drummer inside. This little dude is already scaling his baby gates. And it gives me heartburn. :)

*Happy Weekend!*

Office Talk: Just a Virus!

Question:Is my upper respiratory infection really ‘just a virus’?


Answer: Probably.

Oh, the war on the unnecessary use of antibiotics. I get exhausted just thinking about it. And if I said everything I wanted to on the subject, this post would take all day. But seeing as I’m working this afternoon, where I’ll probably need to talk a few people off of the antibiotic ledge, I don’t have the luxury of doing that. But I do want to touch on a few myths while we’re still in the midst of cold/flu season. Most people have accepted that antibiotics won't treat the common cold. But beyond that? Skipping the antibiotics can still be a hard sell.

1)If my cold turns into a sinus infection, I definitely need antibiotics: Not so! One recent study estimated that only 2% of acute sinusitis episodes are caused by a bacteria. Most often, the same viruses that can cause the common cold, invade the sinuses. How can you be rid of viral sinus infections? Saline nasal rinse (the unsung hero of the nose), Decongestants (Claritin-D, Zyrtec-D or plain Sudafed--which is the ‘–D’ in other products), Nasal steroid sprays (like flonase, which is often used for allergies) and time. And when I mention saline nasal rinse, I’m talking about the RINSE, not the mist. It has to go up one side and out the other. Sound fun? It’s a party. A party that works.

I don’t want to downplay that there are occasionally circumstances where sinus infections can get serious and cause complications as the infection spreads. Or that there are times you would use antibiotics. If you have that cluster of symptoms (facial pressure, headache, upper teeth pain, ear pain and congestion) that so often heralds sinusitis, here are a few of the points of history we use to determine if you might need antibiotics:
-duration of symptoms for greater than two weeks
-initial improvement, followed be re-worsening
-Purulent nasal discharge (no, this does not mean green drainage. Viruses are just as capable of producing green drainage. I’m talking pus-like drainage.)
-True fevers over 100.4
-One-sided symptoms (one sinus is more painful or tender than the rest)
-You are getting married in a few days. Kidding! Sort of. We joke that the bride always gets antibiotics.

If you are unsure, or are worried that things are getting worse, always check with your doctor.

2)If my cold turns into bronchitis, I definitely need antibiotics: Wrong again! Most of these infections are viral. But most people don’t realize that viral bronchitis lasts three weeks. Three whole weeks. This is a long time to be coughing, and most people get fed up after 5 or 6 days and figure it must be time for antibiotics. There is a supplement called pelargonium (found in a product called Umcka and sold at whole foods) that has actually been shown to shorten the duration of viral infections like bronchitis. I recommend that to most of my patients. It’s sort of like Zinc for the common cold. One of the few things that actually has some efficacy.

There are a few exceptions to the viral rule: A)Pertussis, or whooping cough, which is making a resurgence in communities. And, oh, what a nasty bug it is. Made nastier by the fact that it acts like a run of the mill cold during the first few days that are the only time treatment will reduce symptom duration. B)Mycoplasma (a.k.a walking pneumonia) and Chlamydia Pneumonia(a.k.a. not the STD) Infections. These too can seem like a cold in the early stages, which also makes them harder to recognize and treat early. Always talk to your doctor if you are feeling short of breath, are coughing to the point of throwing up (which can be indicative of pertussis) or just aren’t sure if you need to be concerned.

Also, if a fever is present, this may actually indicate flu or pneumonia, because bronchitis doesn’t usually cause a fever.

3)Antibiotics would help me, but you are withholding them to protect communities against bacterial resistance.

This is another one I see a lot. I get the feeling that people think we’re holding back effective treatment so that we don’t hasten bacteria’s goal of outpacing our research to kill them. I can see how this would breed resentment. But the truth is that our primary interest is our patient. We generally don't prescribe them because we know that in the majority of cases, they don't work better than placebo. They don't kill viruses. Additionally, there are plenty of possible harms for the patient as well. Among them: diarrhea (sometimes a potentially dangerous variant called C. Diff that has moved from the hospital to the community), allergic reactions, and a wiping out of your good gut flora. I know that I avoid them for me and my kids unless it’s really necessary.


I am very grateful that we live in an era where we have antibiotics. There are times when antibiotics are necessary. And life-saving. And so I don’t mind a bit if people come in when they feel sick to find out if this might be one of those cases. In fact, I think that’s totally appropriate. Frequently I have other prescriptions to help alleviate their symptoms while the body fights the infections. But if your doctor advises that you don’t need antibiotics for your upper respiratory infection, or asks you to wait a few days before taking antibiotics, at least remember that the odds are in favor of their being right and that they probably have your best interests at heart. And that since it is by far the easier thing to just quickly hand out the drugs, a 'no antibiotic' discussion that takes twice as long may actually indicates that your doctor cares more about your health!

**So, what about you? Do you feel annoyed when your doctor tells you that you don't need antibiotics?**