“Drugs and Poisons in your Home”

To Smokers–A Letter from your Pulmonologist:

I had such great guests for my show last week that I asked them to each contribute some words of their own to be posted on the site.  Read below for an informative and compassionate piece from Dr Douglas Beach, Director of the Division of Pulmonology, Critical Care, and Sleep Medicine at Beth Israel Deaconess Medical Center.  Take it to heart for yourself, or share it with a loved one.  Keep up the good work!–Dr Darria

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As a pulmonologist, I see patients with breathing problems on a daily basis.  Too often do I hear patients express regret about not quitting smoking earlier.  The truth of the matter is that it is never too late!  Quitting smoking is more important than any medicine a doctor can prescribe in preventing long term health problems.  So I encourage all my patients who smoke to try every day to cut back and eventually quit smoking.
Patient who smoke need to be ready to quit smoking.  If you are not ready to quit smoking, you should think spend a minute every day thinking about the reasons why quitting would be a good idea (whether it is for health reasons, or even to put more money in your pocket and less into the tobacco companies enormous profits).  Once you are ready, you should talk to your doctor about ways to help you quit.  Even if you don’t ask, your doctor may ask about ways to help you quit smoking.  Just talking about how to quit smoking is more important that a prescription pad, and there is no quick fix to quitting.  Although there are medicines than can help people quit, making a plan is the critical first step.
Nicotine is a powerful drug, more addictive than any drug that can be bought illegally.  The nicotine found in cigarettes takes between 7-10 seconds to reach the brain.  The thousands of other chemicals in cigarettes are just along for the ride, and they are more toxic than anything you can imagine putting in your body.  Most people remember their first cigarette, which was probably bad experience.  But the nicotine keeps people coming back for more, even though the adverse effects are obvious to even a first time smoker.
Once you are ready to quit, remember a few things:
Set a date.  The first of the month, someone’s birthday, or the day after a particularly stressful week.  Try your best to stick to that date.
Get rid of all the matches, lighters, ashtrays, and that last cigarette you have around.
Tell your family and friends you are going to give it a shot.  Get their support!
If you slip, don’t worry, there is always tomorrow.  Give it another chance!
Finally, using a medicine that replaces the nicotine, like the Nicoderm Patch, Nicotine Gum, or Nicotine Lozenges, replaces the only thing in the cigarettes that your brain is addicted to.  Once you have gotten over those urges, the chances of giving the cigarettes up for good increases 3-fold!  Using another medicine, like Chantix or Buproprion, can increase the chances of quitting even more, just ask your doctor.
Thanks for reading, and GOOD LUCK!
Dr. Beach

Latest TV Episode-Breaking the Smoking Addiction

Did you know that it only takes 7 seconds from the moment a cigarette hits your lips to the time it reaches your brain?

Did you know that drinking milk can help you break the habit? No kidding!

We know so much about cigarette smoking–but I’m sure that you’ll still learn some great tips (like that milk one, above!) from the show.  You may wonder why people still do it at all.  WHY? Because it’s one of the most addictive substances on earth, that’s why.

Bottom line?

  1. NEVER STARTING is the BEST way to “break” the habit– even people who stopped long ago can still feel the pull  every once in a while
  2. It’s NEVER too late to stop–but the sooner you do, the better!
  3. NO ONE said that breaking the habit is easy–it may be one of the most challenging things that a smoker tries to do.  But for a smoker, it is the ONLY thing you can do.  All those fancy medications that I prescribe to my patients? It’s like bringing a watering can to a forrest fire –they may temporarily reduce their symptoms, but they do NOTHING to prevent death.  The only way to treat the deadly consequences of smoking is to STOP.

I had three FANTASTIC guests–Dr Douglas Beach, a pulmonologist at Beth Israel Deaconess Medical Center and Director of the Division of Pulmonary and Critical Care there, Barry Beder, the former director of the Dana Farber Smoking Cessation program, and Mr Thomas Hill, a long-time smoker who bravely came on camera to share his struggles with quitting and get suggestions.  Enjoy the clips yourself, or share them with someone you care about that is struggling with the same fight as our on-camera patient.

Emergency Departments See a Surge in Energy Drink-related Visits

The other night, I took care of another adolescent with an intoxicating and dangerous cocktail of alcohol and energy drinks. I’m not the only one—emergency doctors nationwide are seeing a surge in emergency department (ED) visits from patients that have been drinking energy drinks and other energy-stimulating supplements.  Some products have been banned, including the energy-drink-and-alcohol beverage Four Loko, and the military has banned certain energy/weight-loss supplements from their on-base stores due to concerns that they may have been associated with the deaths of two soldiers.  Unfortunately, these substances are still available in stores, and scores of our children and young people are buying them.

With the majority of these cases and ED visits being in the younger population (a recent study out of the Univeristy of Miami that said that 30-50% of children consume these items),  I started to wonder—what are we and our children consuming, and what do we know about it?

 

(1) What’s in Them?  Good Question.

Unlike medications (even over-the-counter) and soda drinks, which are strictly regulated by the FDA, these energy drinks and supplements are classified as “dietary supplements”.  They don’t have to follow the same strict guidelines for concentration of stimulants, safety requirements, or even publication of their actual ingredients.  Some things that they may contain:

-Caffeine: a 16-ounce can could have more caffeine than four or more caffeinated sodas.  Under FDA rules, soda cannot contain more than 71 milligrams of caffeine.  However, energy drinks, which are considered “dietary supplements” and not soda, can have as much as 500 milligrams. Many may have “caffeine-equivalents” such as guarana, yerba mate, and cocoa, which can have an additive effect on top of the cafeeine

-Sugar: these drinks (the non-diet ones) often have very high levels of sugar –often thirteen teaspoons of sugar or more.

-Amphetamine-like stimulants: Many dietary supplements (such as the kind banned from the military bases), are easily available at health food stores for fat-burning and increased metabolism and are often used by dieters and athletes alike.

 

(2) They raise blood pressure, temperature, and heart rate—sometimes dangerously

According to the American College of Emergency Physicians, “excessive caffeine intake from energy drinks can cause adverse reactions” including dangerous heart rhythms, dangerously high blood pressure, and dehydration.   There have been an increasing number of cases including young people who died after drinking moderate to large quantities of energy drinks and participating in sports. The American Association of Poison Control Centers has also reported an association with seizures, kidney failure, and psychotic episodes.   According to a review article in the Mayo Clinic Proceedings in November 2010, energy drinks were associated with four documented cases of caffeine-associated death, and five of seizures.

 

(3) They do NOT increase tolerance to alcohol.

Many people mix energy drinks with alcohol with the perception that it will enable to them to drink larger volumes of alcohol without becoming intoxicated.  It’s actually quite the opposite—these drinks can actually mask the perception of intoxication—leading people to not realize that they are drunk even when they actually are.  As a result, they drink more, increase their risk-taking, and increase their risk of DUI and even death.  This was exactly what happened with Donte Stallworth, a Cleveland Browns’ wide receiver, who got behind the wheel after drinking several shots of tequila and Red Bull.  He stated that he did not feel drunk at the time of the accident—an accident that killed a pedestrian.

 

(4) The effects can be even more detrimental in children

A recent review article in the journal of Pediatrics highlighted concerns about caffeine in children. It reported that of the 4600 calls to the American Association of Poison Control Centers in 2005, 2600 of those involved patients younger than 19.  The study authors also noted that caffeine could have adverse effects on a developing neurologic and cardiovascular system, as well as potentially creating physical dependence at a very young age.  They stated that “Rigorous review and analysis of the literature reveal that cafeeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents”.

Enjoy holiday activities–but protect yourself from this “false” sense of security!

So—if you followed my advice last week on how to avoid or get over a cold, you should be feeling better by now and ready to join in on the many holiday activities on your schedule! Given the upcoming holidays (and hence holiday parties), I wanted to take this eek to provide a little education, and hopefully some protection for you and your loved ones.

Working in the ER, we daily see the unfortunate consequences of alcohol intoxication.  However, if you are thinking to yourself right now  “I never drive impaired” or “as long as I stay under the legal alcohol limit, I am safe, right?”

NO.

While many of us rely on the legal limit of 0.08% as the “safe threshold”, studies have long shown that even small amounts of alcohol can significantly impair your ability to function or drive. What’s worse, at low levels such as 0.05% (below the legal limit of 0.08%), people are unlikely to show any signs of intoxication (so their passengers and friends do not recognize the impairment), and yet they are 30% more likely to have impaired driving and difficulty stopping and more than TWICE as likely to make incorrect emergency maneuvers.  Even worse, at this level of intoxication, people often do not perceive themselves to be impaired at all, and in some studies, perceive themselves to be better. 

To test function at alcohol levels below the legal limit, a consortium through Boston University, Brown University, and the Maine Maritime Academy tested performance of cadets on a simulator after ingesting enough alcohol to obtain BAC of 0.04%-0.05% (below the legal limit).  The cadets did not know if they were given alcohol or not.  They were then tested on a program that simulated piloting a large merchant vessel through a busy harbor.  Cadets with BAC of 0.04-0.05 performed twenty percent worse than their counterparts with no alcohol.  They also rated themselves as “not intoxicated” as often as those with no alcohol, and, frighteningly, those with alcohol tended to rate themselves as less intoxicated.

So how much alcohol is too much?

  • Blood Alcohol Content (BAC): BAC is a percentage of alcohol in the blood.  A BAC of 0.10 means 0.10% (one tenth of a percent) of a person’s blood is alcohol.
  • Legal alcohol limit: determined by each state, for most is 0.08, but it is lower in some states.
  • One standard drink (according to the Department of Health and Human Services)
    • 12 ounces regular beer
    • 5 ounces wine
    • 1.5 ounces of 80 proof distilled spirit
  • When your stomach is empty, it takes 30-90 minutes for the alcohol to reach its peak effect.  Women have fewer receptors to metabolize their alcohol, so even if they are the same weight as a male, a female will still have a lower tolerance.
  • Translating beverages into levels: (these are averages and will vary depending on the person, the amount of time, and are very rough estimates—a great calculator is available through the Department of Transportation http://www.dot.wisconsin.gov/safety/motorist/drunkdriving/calculator.htm)
    • In a 140 pound woman (64kg)
      • one standard drinkà 0.03% (impairment begins), 2 drinks à 0.05% , 3 drinks à 0.08 – 0.1%
    • In a 180lb male (82kg)
      • One drink à 0.02%, 2 drinks à 0.04%, 3 drinks 0.08%
  • It takes approximately 1 hr to decrease your alcohol level by 0.02%, translating into 70-90 minutes for every drink

Keep yourself safe this holiday season:  Don’t let yourself be lulled into a false sense of security because you’re relying on the “0.08%” rule as a safe cutoff, or because the driver of your car “seems to be ok”.

Many people will be driving home this holiday season with low levels of intoxication and no comprehension of their real impairment.

They are all at a 20-30% higher risk of an unfortunate event.   Don’t let that 20-30% include you or your loved ones.

I wish you and your family a great week—may you “be your best” and enjoy the season.

Ibuprofen and other NSAIDs Linked to Increased Rates of Miscarriage

http://www.cmaj.ca/content/early/2011/09/06/cmaj.110454

A recent study (link above) in the Canadian Medical Association Journal found an increased risk of spontaneous miscarriage in women who took NSAIDs (Ibuprofen, Motrin, Naproxen, Diclofenac, among others) in their first 20 weeks of pregnancy.  This review compared 4,700 women with miscarriage with 47,000 women that did not miscarry, and found that those that took an NSAID in their first 20 weeks of pregnancy had twice the rate of miscarriage. 

It has long been known that these medications should not be used late in pregnancy, but this study inreases the concern for their use earlier as well. 

KEY TAKE-AWAY:Pregnant women should avoid taking these medications without an indepth discussion with their doctor and consider taking Tylenol (Acetaminophen) for pain or fever during pregnancy.

How to Help Doctors Give you the Care You Need at the Emergency Department

Nothing is more terrifying than a health emergency of your own or a loved one.  The fear can make it difficult to think clearly–but this is the most important time to have your thoughts together.  

Help yourself, and help the doctors and nurses trying to care for you, by some taking some precautions beforehand and, if you find yourself in the ED, following these few points: (1) Prepare yourself–be the steward of your own health history (2) Go to the RIGHT ED  (3) Maximize your ability to help the physicians take the best care of you and understand your condition

 

(1) Prepare yourself–Be the Steward of your own health history!

-Many patients assume that, since their primary doctor (or other specialist) works in a group that has the same name as the hospital, that the ER doctor will be able to access those records.  I wish that were the case!!!! Nothing is more frustrating, nor takes more time away that I could be spending time with the patient, than trying to investigate and make phone calls to get list of medications, medical conditions, or allergies.  So, until the medical records allow for sharing of information, the patient must be the steward of their health history with the following lists that you keep in your wallet.  For families with children or elder parents, all parents and/or caregivers should also have this in their wallets, as you never know who would be the first to actually arrive to the ED with the child

1. Medication list — keep this up-to-date with exact medications and doses.   Most important is to just have the NAMES of the medications

2. Allergies — write the specific allergy, and KNOW your reaction.  Many times I’ve had patient’s whose care was delayed because they had an extensive list of allergies but did not know their reactions, and the medication that I needed to give them was on that list.  Often, the allergy was just a little bit of a sensitivity, or maybe even the effect of taking two drugs.  This is crucial to know, as a particular medication that could be life-saving could be delayed as we spend time trying to figure this out. 

3. Medical Conditions — You dont have to drive yourself crazy with the level of detail here, but just have a list.  If you’ve had a pacemaker or defibrillator, have that written.   Diabetes, high blood pressure, a history of a heart arrythmia–these are all important

 

(2) Go to the Right ED

-The “RIGHT” ED is the place where you have received care in the past.  If you had a surgery or procedure done at a particular medical center, or your primary care doctor uses a specific center, then it’s important to go to that Emergency Department, and to go to that same one EVERY time that you need emergency care.  Swapping ED’s based on one being closer or some other convenience factor, when all of your prior care has been received at a different hospital creates a disservice to you, as inevitably the doctor will spend time trying to figure out your past medical history that they could otherwise be spending with you. As an ED doctor, being able to pull up a patient’s old admission records, an old EKG, or just to be able to get your surgeon or other specialist on the phone (and come into the hospital to see you, if its urgent), is crucial, and decreases delays in your care, and unecessary transportations to other hospitals. 

 

(3) Help the physicians to take the best care of you that they can

-ED’s can be so busy and pressured today–stressful for both patients and providers alike–Trust me! When a patient is ill, I want to drill down to their condition as QUICKLY as possible to be able to alleviate their suffering, so there are a few things that patients can do to help.

1.  Tell me your exact symptom–when it started, if it has been constant, if it fluctuates, and what makes it better/worse

2. Have you ever had this same symptom before? If you did, did you seek care, and what did the doctor say it was? (Nothing is worse than, after a 10 minute conversation, the patient telling me off-hand  “well, yes, I felt pretty much the same way the last time I had a heart attack”)

3. Sometimes patients will try to help me by saying where they think the pain is “ie: I think the pain is coming from my spleen” (An acceptable and useful statement if you’ve had spleen pain in the past that was diagnosed, but just distracting if it’s just a guess).  The most helpful thing you can do is point to where it hurts, tell me what makes it worse.  Let me try to figure out which organ it is– otherwise, you can miss giving me important facts, which is the most important thing you can do. 

4. If you think that your family member is waiting too long, or has been triaged inappropriately, calmly but firmly go speak with someone.  If they do not seem to get your message, a great thing is to call your own doctor–be it primary care doctor or specialist related to your complaint.  Speak to them on the phone–if they are concerned, then they can call into the ED, speak to the ED doctor, and accelerate your care. 

As emergency physicians, we truly want to take the very best care of you possible.  I went into this specialty because you see patients at their point of greatest need, and are truly able to intervene and to help them.  As we face more shortages of emergency rooms and greater demand,  taking these steps to maximize the time your doctor can spend at your side (and not running around tracking down your history) will help you to get the best care that my colleagues and I can provide.