Challenge Yourself

CHALLENGE YOURSELF FOR THE REST OF YOUR LIFE

Challenges in general keep us alive. Without them, there is little to look forward to. This, I believe, is the same for everyone, regardless of age. When we are younger, we eagerly anticipate challenges and accept them as part of life because we are told that it’s part of growing up.  Most children are eager to grown up, therefore they look upon challenges as milestones on the way to adulthood. For example, learning to drive, graduating from high school and college, getting the first job, and buying a first home are all challenges that most young adults eagerly accept and accomplish.

As we get older, we tend to eschew change and even new challenges. Our perception may be that “change” and “challenge” are synonymous with “failure” and “work.” The fact is, however, that even failure and work will lead us to a better future if we have persistence. More importantly though, is the idea that we either forget or don’t realize that challenges keep us happy and motivated for the future.

Physical challenges are important for many reasons. Pushing your body to perform at a higher level than the usual function increases endorphin levels, libido, mental clarity, emotional well-being, heart health and metabolism. These benefits lead to longer and more productive lifestyles.

Regardless of one’s age, one of the best ways to ensure that life remains vital and fulfilling is to embrace challenges.

Chronic Pain: It’s Not in Your Head, It’s in Your Brain!

The formal definition of pain as coined by the International Association for the Study of Pain (IASP) is “A noxious sensory and emotional experience.” This means that something not only hurts because your body feels it, but also hurts because it is a negative experience as perceived by your brain. Chronic pain is defined as pain that lasts longer than three months or pain that does not dissipate in an acceptable amount of time for a particular healing process to occur.

Chronic pain specialists work to minimize the severity of pain and its interference on activities of daily living, regardless of whether the pain is due to normal aging and degenerative processes or an injury, such as a surgical procedure or trauma. My approach is to identify, as specifically as possible, the “pain generator.” This is the area of the body—be it muscle, bone, nerve, fat, ligament, etc.—that is causing the pain. Unfortunately, this is usually not a very straight forward process because there may be multiple pain generators and external factors influencing pain and the perception of pain.

In order for a person to experience pain, a succession of events occur. Initially there is “Nociception,” or the injury itself, then there is “Transmission,” which is the pain signal carried by the nerves. Lastly, there is “Processing,” which occurs in the brain.  The brain is the ultimate judge of whether the offending injury hurts or not. Over many years, the study of pain has revealed that these events are not straight forward either. At each level of the pain pathway, there are different factors that can change the overall cycle or procession of the pain signal. As a pain specialist, I try to block the pain at as many points as possible. For example, most medications are used to try to block pain at the level of the injury or nociception. The most common medication that I use for this is the anti-inflammatory type of medication such as Ibuprofen or Naproxen. If medications fail or a patient isn’t a good candidate for a medication regimen, then I try to intercept the pain at the transmission level. I use nerve blocks and steroid injections and other techniques to “calm” the nerve and slow down the pain signal.

The most important aspect of the pain pathway is the processing of pain or what the brain thinks about the information that it is receiving. Studies have shown that not everyone experiences pain the same way; even movies, books and anecdotes will tell you that one person’s pain may be another person’s pleasure. The good news is that despite what doctors and medical therapies may not be able to do to alleviate pain, the brain can.

Research studies done on the psychology of pain have proven that the brain changes in response to pain and that pain can be alleviated by the brain changing in response to specific treatment “exercises.” We now realize that patients have much more control over a very real phenomenon that occurs in the brain to cause chronic pain. For example, it is well known that depression and anxiety reduce the pain threshold and those individuals who suffer from those disturbances are at greater risk of any type of pain becoming chronic. We have also identified that patients who tend to “catastrophize” medical issues and ruminate on the potential negatives of situations are highly likely to develop chronic pain and disability. These emotional states actually make the body and the nervous system more susceptible to pain. On the contrary, similar studies have shown that patients who are in love or who have positive thoughts and hopeful outlooks on their medical conditions are much less likely to suffer with chronic pain.

Cognitive and behavioral therapy is a type of psychology treatment that helps the brain learn to modify and change the pain signal that is coming in from the body. It is real medical therapy and we are just beginning to understand how truly powerful a tool it is in chronic pain management.

It’s Winter; Be Careful to Prevent Falls

Slips and falls in the rain and snow are a major cause of painful traumas, especially in older people this time of year. The worse type of injury is the vertebral fracture. This occurs when a hard fall onto the back or buttock causes one or more of the bones of the spine to fracture and collapse. The fracture is extremely painful because unlike other fractures, it’s position deep in the body prevents it from being immobilized to allow healing and even everyday activities such as sitting up to eat a meal causes movement of the fractured bone.

If you experience a fall and have severe pain that doesn’t improve within one to two weeks and have severe back pain with any position or activity except lying down, more than likely, you have a spinal fracture. It is very important to have a physician evaluate you and order a diagnostic x-ray so that you can receive appropriate treatment in a timely manner.

The treatment for a spinal fracture depends on the severity of pain and on how much the pain limits your everyday activities. Younger adults may have a fracture, but because of good muscle tone and strength surrounding the spine, they might not have such severe pain that prevents their usual activites such as work, dressing, bathing, eating, etc. Older adults however, tend to have less muscle mass and support of the spine so that even sitting at the dinner table to eat a meal is a chore because of severe pain. In less painful fractures, wearing a tight, elastic, low back support belt can be very helpful, along with taking anti-inflammatory medications such as Advil or Aleve. These fractures may take up to six months to a year to heal naturally.

For older adults who have severe pain that prevents them from participating in their usual activities of daily living, we recommend a curative procedure called a Percutaneous Balloon Kyphoplasty. The procedure fixes the fracture by injecting cement into the bone through a thin, hollow needle. The cement is the same that is used in knee and hip replacement surgeries. It hardens immediately and the severe pain is gone immediately as well. The procedure is safe, done in the office under conscious sedation and takes one to two hours. There are no physical restrictions after the procedure and since the fracture is then fixed, there is no need for any strong pain medications.

I recommend that the procedure be done as soon as the fracture is identified if there is severe pain. If the fracture is allowed to heal on its own, it will likely heal with a deformity of the bone that causes the spine to bend forward, called kyphosis. Kyphosis can lead to long term health problems including respiratory diseases and chronic back pain. An MRI of the spine is usually ordered by the doctor to ensure that the fracture is still new enough to be fixed. Usually the MRI will show inflammation of the bone due to the fracture even six months after the fall has occurred. Once the bone heals, usually six months to a year after the fall, nothing can be done to reverse the deformity.

The best option of course is to avoid falls and injuries. “An ounce of prevention is worth a pound of cure,” as our friend, Benjamin Franklin, says. Wear shoes with good treading and if you need a cane or a walker, use it! Do as much safe exercise as you can to keep your back and spine strong and healthy.

 

Get Motivated!

Here we are again—a New Year and a new start for goals, aspirations and dreams. Actually, every day of our lives is an opportunity for a fresh start, but most of us tend to use January as the starting line for change. The New Year is a time to start a weight loss plan or fitness/work out plan to get healthier and look better.

As I get older I find that it’s becoming harder and harder to motivate myself to do the same things that I used to even though I know what is good for me to do. For example, I’ve always been athletic and not only interested in exercise, but I use it as a mental escape and a way to relieve stress, and last but not least, to look good in my clothes and feel attractive.

I frequently counsel patients on the importance of staying active despite growing older, but I realize from personal experience that this is much easier said than done. One important realization that I’ve made, however, is that it’s not easy for anyone. Some people are just more motivated than others or they work harder to find their motivation to exercise and stay as healthy as possible. I heard a quote from a professional body builder who said that it’s never convenient for him to work out, but he made a commitment to himself to do it in order to reach his goals and be successful. One can extrapolate this mantra to any goal in life and it was somehow particularly soothing to hear someone else verbalize that it’s not easy for them to work out—even when that’s what they do for a living.

I remember my sister saying years ago, “Leslie, you take good care of yourself”. Ironically, my motivation for exercising and staying in shape had never included being healthier or taking care of myself, but as she recognized, that’s exactly what I was doing. I believe we should look at exercise in this way first and foremost because that’s what it does for us. Exercise keeps the heart healthy, lowers blood pressure, prevents and reduces depression, lowers stress and keeps us looking and feeling younger, to name a few benefits.

Another reason to exercise and get fit is to save money. It’s expensive to be unhealthy. Many people who don’t exercise or eat right have hypertension, diabetes, joint disease, chronic pain, insomnia and anxiety. I’ve heard too many patients worry about how they’re going to pay for their medications and because of the expense they don’t have money for enjoyable activities. Taking care of yourself is another way to gain control of your finances, health and your life. Let’s not be so complacent that we’d rather spend money on a pill for a preventable malady than work to keep ourselves healthy. We are responsible for our own health just as we are responsible for paying taxes and taking out the trash.

For many, getting healthier is a major change in a way of life. Therefore, it’s best to have patience and take it one step and one day at a time. The most important part of being and staying healthy is about what you eat. Start with a good meal plan and lose weight the healthy way. Losing weight has a positive feedback effect of losing more weight because of having increased energy and that subsequently encourages increasing activity. Most fitness professionals will tell you that your diet is 75% of the work of being in shape. This January, make the first step to eat right and the rest will follow.

 

Who will the Future Doctors Be?

I worry about the future of medicine, of doctors in particular, as the healthcare laws, mandates and reforms continue to change and evolve. It seems to me that outside of clinical and bench research and resultant treatment advances, few of the healthcare changes are occurring for patient benefit and certainly none are for the benefit of the doctor.

The outcry for “Healthcare Initiatives” by government and lawmakers because of the continued escalation of dollars spent on individuals’ use of medications, hospital services and insurance coverage, is never ending. Unfortunately, government’s answer to the problem never focuses on the root issue and therefore their proposals for fixing the situation will never be successful. A patient recently asked me, “How will Trump’s election and health care changes affect you?” My answer is that regardless of what Trump does or doesn’t do, most assuredly the changes won’t benefit me or other doctors in any way. We doctors can only brace ourselves for the impact and hope it doesn’t hurt too much.

For decades, the answer to rising healthcare costs has been to reduce doctors’ reimbursement rates. Doctors who have had a large percentage of their patients come from poor communities or who depend largely on government subsidized reimbursement (Medicare/Medical/etc.) have had to close their practices or work for someone else, such as Kaiser Health System, in order to have a guaranteed income. Not only are reimbursement rates reduced yearly, which is analogous to being demoted or taking a pay cut every year, doctors are actually being PENALIZED for not participating in more paperwork that does not improve patients’ health and adds even more uncompensated time to our days and increases our overhead. For example, Medicare devised the PQRS initiative, which stands for “Physician’s Quality Reporting System” that supposedly improves patient care by having doctors fill out various questionnaires regarding aspects of patients’ care and medical screening whether they are related to an individual doctors’ treatment of the patient or not. Doctors are being penalized by an additional 6% or more back to 2013 if they have not submitted the required paperwork. Unless something changes, future penalties are already scheduled up to 2018 for paperwork not submitted this year. The PQRS does not improve patient health outcomes; it gives the government a reason to do more of what they’re going to do anyway—make doctors pay.

It is ironic to me that the Medical Doctor, as a career, could be careening down such a treacherous road. I was eleven when I decided to become a doctor. I was told that it was a very noble profession but that I would have to sacrifice much in order to accomplish that goal. I would have to study hard, spend many years in school, and delay gratification for at least twelve years longer than most anyone else who wasn’t trying to do the same. I was warned that I would have to work very hard once I became a doctor and that my nights and weekends would not be my own. I was assured, however, that the reward would be worth it. The reward would be prestige, respect, financial comfort and independence, to name a few. Disappointingly, the promised reward is becoming ever more elusive.

I enjoy being a doctor, despite the undercut reward because I am gratified by working hard, taking care of people and “doing good.”  Doctors are smart, kind people, who make decisions every day about how to best care for someone else. However, every person deserves to make decisions for their best benefit, especially if it concerns survival. I worry about what kind of people will become doctors in the future.The carrot should always be bigger than the stick and right now the carrot is shrinking at an alarming rate. The way it stands now, physicians are often the scapegoats and worker bees that businessmen and corporations oftentimes profit from unfairly. Government decisions are squeezing the very people who have sacrificed years of blood, sweat, and tears for their careers. Although I won’t quit, I for one would not make the same choice knowing what a doctor’s work and life would be like at this time. I am fearful about whether there will be any kind, compassionate, capable physicians when I need one in my old age. Despite all, I will remain hopeful that someday, smarter, wiser and gutsier politicians will step up and start looking out for the future of this country and its people.

 

Coming of Age

As we live our lives we are apt to experience a multitude of “coming of age” moments. One of those moments is when we realize that an elder in our family circle, who was previously known as the “care giver,” now needs us to care for them in a way that we are unaccustomed. Some people seem to grow old and infirm inordinately quickly; perhaps from too many heartaches and disappointments. Life isn’t easy but I believe that we are here to help each other ease the path. There oftentimes is no “START” sign that alerts us to the fact that a family member or friend now needs our help navigating their health issues.

When I moved to California my mom would visit from the East coast with her oversized luggage in tow. Seriously, the airlines marked it with a “HEAVY” sticker every time because she would also pack her favorite snacks. On one occasion while I was picking her up at Oakland airport, I was unable to lift her big red bag into my Jeep Wrangler. I left her at the curb to get the car but I had to come back for her help. In retrospect she was having trouble walking due to leg pain but she never said a word about that. She told me to just go ahead and put the bag in the Jeep myself and I started laughing because it was HUGE. Normally, I can handle most physical tasks, but I was literally afraid of busting a gut or something. Eventually, we hoisted the bag into the car together and laughed all the way home. My mother never told me when she was hurting or that she needed help and I therefore assumed she was doing just fine. I had no reason to suspect that she wasn’t the same strong woman that I had known all my life.  When she went to the hospital in Pittsburgh for unclear reasons, but related to abdominal pain, I assumed she would tolerate the event with minimal difficulty. Devastatingly, my mom died unexpectedly during that hospitalization. My biggest regret is that I wasn’t there to support her when she needed me.

Older patients may get better medical care when they have family with them at their doctor visits or when they are in the hospital. Understandably, this isn’t always possible due to social, economic and logistic reasons; however, the reason they do get better care when accompanied by someone who knows and cares for them is multifactorial. The art of medicine and the medical practice model have changed vastly over the last fifty years. As a result, the amount of time that a doctor has to spend with her patients and conceptualize an idea of the problem and issues to focus on is reduced to a fraction of what it should be. If a patient comes to the office alone, we have only the information that they can give us to help formulate a diagnosis and treatment plan. Not infrequently, patients can’t remember specific facts or incidents surrounding the issues for which they are seeking help. They may be overwhelmed by the medical experience or may have impairments with memory or thought processes.  Patients may even be too embarrassed to mention issues that are significant and crucial for the doctor to know. Also, due to time restrictions with each patient, we physicians are losing the ability to develop trusting relationships with the people for whom we are assuming responsibility. Patients are reticent to heed the advice of a doctor they don’t know well or if they don’t understand the information that is being given to them.

In my experience, if a close relative or friend accompanies a patient, I have an opportunity to see a more three dimensional view of that person’s medical issues and how they are affecting her life and to what degree. Even if that support person is only present for the initial office visit, it is helpful to have a familiar point person who can be contacted if I have future questions or concerns.  Also, my treatment of a particular pain issue may involve medications or therapies that an older patient is unacquainted with. I do my best to teach and explain the rationale behind all of my decisions and treatment plans, but it is frequently much easier if I can simultaneously relay the information to the support person who may have a better understanding of my thoughts as well as the ability to reiterate the recommendations after the office visit to the patient.

All of the aspects of the complex medical system we have today along with the numerous health issues that people are dealing with make it more important than ever that we take the time, whenever possible, to be there for our friends and family. Sometimes we might just have to insist to be an “extra ear” to accompany our family member but most likely the offer will come as a relief in knowing that they are not alone.

Nerve Blocks and Steroid Injections

Anesthesiologists have been performing nerve blocks for surgical anesthesia for centuries to allow a patient to undergo an operative procedure more comfortably with less general anesthetic and therefore fewer side effects. Modern anesthesiologists prefer to administer more regional anesthetics (i.e., anesthetizing only a specific region of the body) over a general anesthetic whenever possible because we find that patients have less pain, nausea and delirium postoperatively, as well as shorter, if not outpatient, hospital stays. Typical types of surgery that would fall into this category are surgeries on extremities including total hip and knee replacements; leg, foot, arm, shoulder and hand surgeries.

The pain management specialty was borne from the desire to help more patients who are not having surgery, but who are in pain nonetheless, with the same techniques. By offering interventional techniques such as nerve blocks and steroid injections, we can treat outpatient pain problems without having to rely on or use high dose oral pain medications. The most commonly performed procedures are epidural steroid injections for neck, mid-back and low back pain. Herniated discs and stenosis (spinal arthritis) can cause inflammation and swelling of spinal nerves to create severe pain in the neck, arms, low back and/or legs. The injection of steroid medication into the epidural space, which surrounds the nerves, helps reduce the swelling and inflammation and pain. We often inject a local anesthetic, aka “numbing medication,” with the steroid for some immediate pain relief, which is what makes the injection a “block.” Oftentimes the anti-inflammatory effect of the steroid provides long lasting pain relief for months or years; however, occasionally the pain relief effect may only last days or weeks. The difference in the result from person to person depends on multiple factors including: severity of the disc herniation or arthritis, weight burden on the spine, muscle tone surrounding the spine, and amount of inflammation, to name a few. Unfortunately, these steroids don’t cure the ultimate cause of the pain, but they can and do, for most people, improve function and reliance on pain medications. The injections can safely be repeated if the pain returns, however, the best way to avoid future pain exacerbations is to optimize spine health with weight reduction, core strength training and stress reduction/management.

As with any medical technique or recommendation, the benefit of the treatment should far exceed the risk. Cervical and thoracic epidural injections inherently carry more risk to perform because the spinal cord can be injured if they are not performed correctly. The spinal cord terminates at L2 and exists as long spaghetti-like nerve endings below this level, so lumbar epidural injections carry less risk of spinal injury, however all injections should only be performed by specialty trained doctors. Patients who are at higher risk for complications from injections include those with diabetes or bleeding disorders or those who are taking blood thinners. If steroid injections are done too frequently, side effects can occur including adrenal suppression (the body doesn’t make its own steroid hormones), early cataracts and hormonal imbalances.

My pain management philosophy is to use a balance of treatment options so the patient isn’t at higher risk from any one particular type of treatment. Also, the complexities of chronic pain are better addressed by using a treatment plan that is directed at alleviating more than one aspect of the pain. Oftentimes pain, anxiety, depression, insomnia, isolationism, anger and embarrassment are intertwined and there just isn’t one type of medication or injection or treatment that will make all of those symptoms resolve simultaneously. The best treatment plan is one that will reduce pain and increase quality of life and function for the short term and the long term with the least side effects.

“What Happened?”

This was what my new IT consultant asked me regarding the prescription narcotic addiction epidemic that this country is currently being plagued by. He said he wanted to get the information directly from an expert. So here is a more historical, although still oversimplified version of this complex issue.

Chronic pain is a medical problem that has existed for centuries. Soldiers in WWI were diagnosed with Complex Regional Pain Syndrome due to severe nerve injury, although it wasn’t named as such for decades later. Since the development of the Pain Management specialty in the early 1950s, new ways of treating chronic pain have been adopted into the physician’s armamentarium. In the 1980s, opioids or morphine like medications, i.e. narcotics, gained traction as legitimate and appropriate medications to treat chronic pain. The philosophy at that time and until relatively recently was, “give patients as much as they need to be comfortable.” Essentially what this meant was, if they continued to complain of pain, increase the dose. The risk of narcotic addiction was deemed “low” or less than 1% if the patient was being treated for a pain process. As a result, many people were helped and able to live more productive lives by the use of narcotic medications for severe pain.

Now, fast forward to 2003 when a national initiative occurred to treat pain as “the fifth vital sign.” The four vital signs to assess someone’s wellbeing or acute medical state are: Temperature, Heart Rate, Blood Pressure, and Respiratory Rate. As a new diagnostic tool, physicians were asked to evaluate and treat vital sign number five: Pain Score. I believe that it is absolutely important to consider pain a vital sign for an acute situation such as for the postoperative assessment or acute injury scenario. In medicine, it is accepted that untreated acute pain can cause a multitude of complications including hypertension, hyperglycemia, anxiety, depression and chronic pain, to name a few. As a result of the initiative, which turned out to be largely funded by Big Pharma; who has patents on “designer” narcotic medications; many physicians who weren’t previously prescribing pain medications began to do so in the effort to help more people.

Chronic pain is a complicated process commonly confounded by factors that aren’t directly related to physical changes. Any kind of chronic pain can be worsened by depression, anxiety or any type of external stressor. For example, if a person with chronic low back pain is also undergoing a divorce or dealing with a death in the family, the severity of pain will seem much worse because their pain tolerance is lower. Emotional distress can make a preexisting pain feel more intense because one’s coping mechanisms are being overloaded and compromised by the additional burden. Narcotic pain medications should not be used in these circumstances and the dose for someone already taking them should not be increased to respond to this type of exacerbation. When narcotics are used to treat pain associated with a weakened coping mechanism, or “emotional pain,” the risk of long term use and addiction are greater. Also, there are other ways to treat pain besides medication such as nerve blocks, steroid injections, physical therapy, chiropractic treatments, biofeedback and relaxation, and acupuncture, that should be incorporated into both short and long term plans to avoid narcotic side effects.

Using a pain score to decide the amount of narcotic medication needed without also incorporating other assessment tools such as physical functional level, emotional state, mental function and overall health, can lead to over-prescribing, continuous dose escalation and an increased risk of overdose. Narcotics also have what is called a “ceiling effect” which means that there is a limit to the pain relieving effect it can have despite how large the dose is. This is particularly important because there is no ceiling effect to the risk of overdose. The larger the dose, the more likely it is that a person can inadvertently overdose with it. Moreover, if a person is also taking a medication for anxiety and/or insomnia and/or drinking alcohol and/or taking illegal drugs, the risk of overdose then becomes exponentially higher because these factors all lower the threshold for overdose when combined with a narcotic medication.

In order to restrain the prescription addiction epidemic, we all need to accept responsibility and act accordingly. Big Pharma should fund treatment centers for patients who have succumbed to addiction disorders to prescription narcotics. Physicians who want to continue to prescribe narcotics for chronic pain should have appropriate training or refer to those who do. Patients need to have realistic treatment goals and inform their doctors of factors that could increase their risk of addiction. Families of patients with chronic pain and or addiction need to get involved by providing additional support or information in the patient-physician treatment dynamic when needed. I appreciate it when family members accompany patients to office visits because it gives me another perspective on their home lives and functional levels that the patients don’t necessarily divulge.

My philosophy and approach to treating chronic pain is to balance the treatment modalities so that the patient has the benefit of different treatments that lower the risk of side effects to any one particular approach. I use medications to treat a specific diagnosis and cause of pain; which may or may not be narcotic analgesics; along with steroid injections or nerve blocks that can break the cycle of pain and minimize the dose needed of pain medications.The goal of pain management is to reduce the suffering from pain and minimize disability in the safest possible way for the greatest benefit and least harm.

 

The Anesthesiologist: Your Medical Lifeguard.

I’ve been reading news articles lately about increased occurrences of patients who have to pay for costly anesthesiology services that are considered “out of network” with their insurance plans. Understandably, people are angry at these unexpected costs above what they’ve already agreed to pay or have paid for their surgical procedures. The insurance companies are taking advantage of all of us. As a doctor, I’m paid consistently less over time for the same hard work and medical expertise and as a patient I know that my insurance premiums and out of pocket costs keep going higher despite the fact that I have no health issues. Apparently, insurance companies are now unwilling to give fair reimbursement contracts to anesthesiology groups for their work and in turn anesthesiologists are deciding to not take less payment than they deserve. This is why the patient then is billed for something that is entirely out of their control and unfairly uncovered by some insurance plans. I believe the answer is to hold insurance companies accountable to offer affordable medical coverage for patients and a fair payment system for all doctors’ services. Something that I’ve also come to realize however, is that few people, even other physicians, understand who and what an Anesthesiologist actually does.

An anesthesiologist is a physician who has completed four years of medical school, four years of residency and in some cases up to three more years of fellowship for a specific specialty such as Pain Management, Cardiac or Pediatric anesthesiology, for example. The anesthesiologist’s role in the operating room is critical. We are there to make sure that you live through whatever surgical or non-surgical procedure you might need. In most cases surgery is a traumatic experience for the body, and depending upon the age, health status and type of surgery involved, the risk of complications or death can be immense. Unfortunately, even a seemingly healthy person can have an adverse outcome during or following surgery.

It is the anesthesiologist’s job to evaluate the patient in relation to the type of surgery needed, then devise a safe plan to successfully take them through the surgery with the least amount of stress, pain and side effects. We’re actually trained to have plans B and C in mind before going into the operating room with a patient to make sure that even the unexpected is expected.

“Putting people to sleep” is what most people know about anesthesiology. This is, in fact, an inaccurate synopsis of the specialty. A good doctor knows when not to put a patient to sleep and oftentimes the safest option is what is called a “regional anesthetic” which puts only the part of the body that is having surgery to sleep. A knee or hip replacement surgery, for example, is often done with an epidural or spinal injection that makes the person numb from the waist or groin down for the duration of the surgery. In this way, the patient is exposed to less anesthetic. An anesthetic is a medication or compound that causes loss of the ability to perceive pain.

All general anesthetics can affect heart, lung, kidney and liver function. In patients who are already ill or elderly, the anesthetic itself can be harmful. Anesthesiologists provide second to second monitoring during the surgery to ensure that a patient’s heart, lungs and kidneys are not being stressed. We are very knowledgeable of various specialties of medicine including cardiology, neurology, pulmonology, and nephrology because we need to anticipate how the body might be affected by surgical trauma and stress and know how to treat any emergencies that might arise to ensure the least possible harm from surgery. We are also real time pharmacologists as it is important for us to know how different drugs interact with each other and with the anesthetics we might need to use in addition to the medications that the patient might normally take.

Obviously, no one goes to the hospital to have anesthesia, but no one wants to have surgery without it either. Anesthesiologist services should never be an additional cost to the patient who needs non-elective surgery. Hopefully, we will eventually find a solution to the ongoing abuse by insurance companies on their insured members and medical providers.

Quit Smoking – It’s Bad for your Cat

There is now an anti-smoking ad that is trying to appeal to smokers’ love for their cats. Cats that live in the homes of smokers are more likely to die of cancer and other diseases.  If it’s not a powerful enough reason to quit for your own health or for the sake of your human family, then by all means, quit for your cat. Allow me to give you some specific and concrete information about why smoking is bad for you and your cat.

I speak to people everyday about how their smoking addiction is hurting their health. For the most part, people understand that smoking is “bad” and that they are at an increased risk of cancer. It seems though, that their belief is that the harmful effects of smoking are far off into the future and something to worry about “later.” This couldn’t be further from the truth, because the harmful effects of smoking are affecting organ function now on a day to day basis. Far before causing cancer, smoking causes COPD, Cataracts, Crohn’s disease, Rheumatoid arthritis, Infertility, Impotence, Psoriasis, Reynaud’s phenomenon and many other illnesses. Smokers have a general life expectancy of ten years less than non-smokers.

There are many toxic elements in tobacco, even smokeless tobacco, that cause disease and illness. Tobacco smoke contains over 4,000 chemical compounds including carbon monoxide, arsenic, cyanide and formaldehyde. E-cigarettes aren’t currently monitored or controlled by the FDA, so there are large discrepancies in content from manufacturer to manufacturer, but formaldehyde and other cancer causing compounds have also been found in the solution that is then mixed with nicotine in the cartridges. Even the “nicotine-free” cartridges have been found to have traceable amounts of nicotine.

Obviously, inhaling the poisons in cigarettes is harmful, but nicotine itself is a poison in the body beyond its addictive properties. Nicotine causes vasoconstriction or tightening of the arteries of the body so that blood doesn’t flow as quickly and easily to the places that it needs to go. Blood carries nutrients and oxygen to skin, muscles, nerves, bone and soft tissues. Some tissues don’t have blood flowing to them directly and they have to rely on nearby blood vessels to leak nutrients and oxygen by diffusion to get what they need. A person who smokes is automatically making their heart work harder by having to push blood into the body against the resistance of the narrowed arteries. This causes high blood pressure. The body works harder to get blood flowing therefore it has to decide which organs need the blood and oxygen the most. The brain, heart, liver, lungs and kidneys are the “vessel rich” organs that need it the most. The skin, nerves, bones, discs of the spine, ligaments and other areas get less. Skin is the largest organ of the body and its appearance is a tell tale sign of what’s happening on the inside of the body. Smokers look older than they are because their skin isn’t getting enough blood flow and oxygen causing early wrinkles, sagging and a dull, dry, off color look.

More and more studies on the effects of tobacco use are showing that chronic pain, especially neck and low back, is directly related to smoking. The discs of the spine only get oxygen and nutrients through passive diffusion of blood flow from nearby spinal arteries. Discs that don’t get proper blood flow and nutrients are more likely to have early degeneration and lose their cushion effect on the spine which can cause nerve pain and damage. Slower tissue growth and healing is a major problem for all smokers whether they are healing from a relatively minor injury or surgery. Any type of chronic pain is made worse by smoking tobacco or e-cigarettes because those toxic elements accumulate in the tissues and prevent the body from healing itself. Unfortunately chronic pain isn’t always preventable or treatable but the decision to smoke can be changed and the harmful effects of smoking can be reversed if done early enough.