A Silent Winter Killer

We’re having a bit of a cold snap here in northern California right now, and I have a string of shifts in the ER coming up over the next several days. So, I have “raised my antennae” for that common, silent killer of the season – carbon monoxide.

It is likely that every year hundreds of people die in the U.S. due to carbon monoxide (CO) poisoning. In fact, it is the most common cause of poisoning death in this country. There is no way to know just how many people are poisoned by CO each year, as many cases, including fatal cases, likely go undiagnosed.

CO is a colorless, odorless, tasteless gas that is the product of incomplete combustion. It poisons the red blood cells so that they cannot carry enough oxygen to supply our vital organs. The reason we start to see more cases of CO poisoning at this time of year is because folks start turning their gas furnaces on (and, occasionally, these furnaces are faulty, resulting in incomplete combustion and CO production). Sadly, when the temperatures really plummet or power outages occur, we’ll see cases where a family has brought a charcoal grill indoors to supplement heating the home. This is a recipe for disaster as these grills put off a tremendous amount of CO in poorly ventilated areas. Sometimes, these families just don’t wake up. Other causes of CO poisoning include faulty chimneys, faulty gas water heaters, faulty exhaust systems in cars, house fires in which victims were trapped, and intentional/suicidal exposures.

I teach our medical students and residents to keep a high index of suspicion for CO poisoning as it can present quite similarly to another very common problem we see this time of year – the “flu.” Patients with CO poisoning tend to complain of headache, nausea, and vomiting. Our ER is full of folks with headache, nausea and vomiting right now. So, how to tell if it’s CO? A big clue is if an entire family gets sick at the same time. The children often show the first signs due to their higher metabolism, but Mom and Dad are likely to be a bit ill as well. Another clue is if the family pet is throwing up. Dogs and cats don’t get the same winter viruses we do. Other symptoms of CO poisoning include dizziness, confusion and chest pain.

So, how to prevent CO poisoning? Most importantly, get a CO detector installed in your home. They’re available for a reasonable price at most hardware stores. You should put detectors in areas where the risk of CO production is the greatest – rooms with gas burning appliances, fireplaces, etc. And, don’t forget to check these detectors periodically to be sure they’re working, just as you do your smoke detectors.

Other steps: get your furnace and chimney inspected to be sure they are functioning properly; don’t let your car warm up in your garage (even though it’s tempting to climb into a toasty warm vehicle on these cold mornings!); and, of course, never bring any form of charcoal or gas grill indoors to supplement heating your home. This is also important advice for winter campers to heed, as I’m sure Dr. Auerbach (“Medicine for the Outdoors”) would agree – NEVER put a gas or propane-burning piece of equipment inside your tent. Many outdoor lovers have met untimely demises putting their camp stove in the tent “just to warm it up a bit.”

And finally, if you are concerned that you or your family members are suffering from CO poisoning, get out of the house immediately, call 9-1-1 to get the fire department and paramedics on the way (especially if anyone appears extremely ill or difficult to arouse), and get to a local ER for evaluation.

Management of CO poisoning includes use of high concentrations of oxygen, and, sometimes, use of a hyperbaric oxygen chamber (a “dive chamber”). This flushes the CO out of the bloodstream and, over time, out of the tissues. But, even with treatment, victims of significant CO poisoning have a high risk of permanent neurological or psychiatric abnormalities (such as memory difficulty or personality changes). So, as in so many things, “an ounce of prevention is worth a pound of cure.” Why not stop off at your neighborhood hardware store on your way home today and pick up a CO detector?

Stay alert and stay safe,
Dr. Bob

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Dealing with Dolby

One of the fun parts of this time of year is all the new movie releases. I caught one last week, "Deck the Halls." Funny, but it could've been a "rental."

If you're fond of the "big screen," but find the sound level just a bit too loud, here's a tip on what NOT to do - learned from a very nice lady in my ER. I picked up her chart and the chief complaint was "foreign body in ear." The hairs on my neck stood up just a bit, as these foreign bodies can be a little tricky to get out.

As I walked into the room, there sat a well-dressed middle aged lady with a sheepish grin on her face. It seems that she had just come from a most enjoyable movie. But, as the film started, she found the sound level a bit uncomfortable. So, she rummaged through her purse to find something to use to dampen the sound. And, there they were - her pack of Tic Tacs. Well, she deftly popped one into each ear, then sat back and comfortably enjoyed the feature presentation.

When the film ended, she turned her head to her shoulder and put her finger in her ear... but, no Tic Tac! No matter how she tried, there was no retrieving the breath mint, so she headed to the Stanford ER.

I looked in her ear with my otoscope, and sure enough, there, shining white and bright, was the end of a Tic Tac. I scrounged up a small suction catheter, attached it to wall suction, then placed it carefully in her ear, and, fortunately, the surface of the mint was perfectly smooth. The mint was sucked up tightly to my catheter and out it came!

As I was mentally congratulating myself on choosing just the right tool to get a slippery foreign object out of a tight spot, the patient looked at me and asked if I could also get the one out of her other ear!

Well, I went “two-for-two.” After successful extraction of both Tic Tacs, this pleasant lady was ready for discharge from the ER. I advised that the next time she found Dolby to be a bit too loud she might try using large pieces of Kleenex as ear plugs. And, as she left, I complemented her on her remarkably fresh smelling ear lobes...

Stay alert and stay safe,
Dr. Bob

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Emergency Medicine - All About the "ABCs"

There is a universal truth in Emergency Medicine when taking care of critically ill or injured patients, and that is, “always remember the ABCs”. (My first grade teacher, Mrs. Goldstein, would be very proud!) In Emergency Medicine, however, the “ABCs” stand for “Airway”, “Breathing”, and “Circulation”… and in that order. Serious compromise of any one of these 3 physiologic functions can mean rapid death for the patient. It is commonly understood that the brain, starved of oxygen for 4 minutes, will begin to suffer damage, which can become irreversible after only 7 minutes. There are 3 key components in keeping the brain bathed in oxygen rich blood: an open airway passage, an intact breathing mechanism, and an effective circulation of blood.

Whenever we assess any patient in the Emergency Department, Emergency Physicians make a determination regarding that person’s “ABCs”. Often it is clear that the “ABCs” are intact, as when the patient is able to give us a history concerning their visit to the E.D. for, say, their injured ankle. They have an open airway and intact breathing – otherwise they would be unable to speak – and they have an intact circulation – a circulation adequate to pump oxygen rich blood to the brain, feeding those neurologic centers that allow the patient to recall their history and to perform the mechanics of speaking. At other times, it is clear that the “ABCs” are NOT intact, and require immediate intervention. A common example is the victim of cardiac arrest – lying on the ground, unconscious, blue, without any breathing or pulse. This victim needs someone to quickly step up and open his Airway, provide rescue Breathing, and then do cardiac compressions (providing artificial Circulation). This is, of course, the basic, yet critical, sequence of Cardiopulmonary Resuscitation (CPR) as advocated by the American Red Cross and the American Heart Association.

It is just as important for laypeople who are attempting to provide emergency care to a person in the prehospital environment (first aid) to recall and assess the proper sequence of the “ABCs”. Is the person’s airway open and patent – allowing air to move in and out? Is the patient breathing effectively – exchanging enough air with each breath? Is the victim’s circulation adequate to perfuse the brain and other vital organs with enough oxygen rich blood? If the answer is “no” to any one of these questions, then the rescuer must act immediately, addressing the issues in sequence. There is no use to try to provide artificial Breathing if the Airway is not open, as there will be no way for the air to enter the breathing tubes. Likewise, providing external chest compressions is unlikely to be of great benefit if the victim lacks an intact airway and breathing.

So, if called into action to handle any apparent emergency in the street or in the woods, start by assessing the Airway, the Breathing and the Circulation. A basic CPR class (through the American Red Cross or the American Heart Associate) is an excellent way to get the basics on the “ABCs”.

Stay alert and stay safe,

Dr. Bob

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Why Is It Taking SO Long?!

One of the biggest complaints I hear people express about visiting the ER is, “Why did it take so long?! I just had a ______________ (you can fill in the blank with: sprained ankle, little cut, sore throat, etc., etc.)!”

Without a doubt, care in the ER often takes longer than most of us would like – the patient, the patient’s family, the ER doctor, the nurse – everyone! Let me try to shed a bit of light on why this is.

First of all, every ER has a finite amount of resources. A finite number of treatment rooms, a finite number of doctors, a finite number of nurses, etc., etc., etc. Almost every ER Director would like to have more rooms in which to see patients coming to us for care, but our resources are constrained (though I am, on a daily basis, struggling and scrapping for more space!). Given that our resources are limited, we have to do the best we can for all of our patients. This generally involves a process of “triaging” patients. The term “triage” comes from a French word meaning “to sort.” So, when we triage patients, we are trying to get the best possible feeling of why a patient has come to the ER – what the symptoms are and what MIGHT be causing them. This allows us to prioritize patients and make the most of our limited resources. We try to ensure that patients with potentially life or limb threatening issues are seen first, and then those who have less pressing problems (these latter cases tend to be seen in the order that they arrive in the ER). This could mean that if you’re in the ER with a sprained ankle, you may have to wait a bit while patients with chest pain (possible heart attack), weakness (possible stroke), etc. go before you.

Once you are seen by the doctor (or another advanced provider such as a physician’s assistant or nurse practitioner), further time is needed for that person to get your history and do a physical examination. Remember, the details the ER doc needs will be a bit more extensive than your private physician might need, because the ER physician generally doesn’t know you or your medical history at all. Therefore, we need to get more info, so that we understand “where you’re coming from,” and can better decide how to approach your problem, both in terms of diagnosis and treatment.

After the doctor gets an idea of the possible things that could be going on, s/he develops a “differential diagnosis.” That’s a laundry list of all the possible things that could be causing your problem, generally ranked from most severe possibilities to least severe. Then the doctor must begin to rule out, as needed, the worst things that could be going on, and ultimately get down to a “short list” of what’s most likely. This may involve doing some diagnostic testing – blood tests, x-rays (including CT scans), etc.., and/or it may involved getting an opinion from an expert consultant. All of these tests/consults take additional time. The thing to keep in mind, however, is that the ER is really the ONLY location that essentially any patient with essentially any problem can come and get some pretty definitive “same day” answers about an acute health problem or injury. No other office or clinic has such ready access to such a wide array of diagnostic capabilities as the ER. Outside the ER, the evaluation of a new problem may take days to weeks (or even months). That makes a several hour evaluation in the ER seem a bit more reasonable doesn’t it?

If, however, you are a patient with “a simple cut,” you might still have to spend more time in the ER than you'd like, because your care providers may be simultaneously dealing with multiple other patients with more serious illnesses or injuries. This doesn’t mean that YOU are less important to them, just that YOUR MEDICAL ISSUE appears less urgent at that point in time. Many ERs have developed alternative “tracks” (e.g., “fast tracks”) for patients with less urgent problems to get in and out of the ER faster, without getting tied up in the more critical care going on at the same time. Nevertheless, even these resources are finite, and may, at times, be pushed beyond capacity.

So, if you find yourself playing the “waiting game” in your local ER, try to be patient. Take some solace in the fact that you are not requiring “intensive resources” to take care of your problem (remember, no one wants to be “an interesting case”!). You should feel empowered to request an estimate of how long your wait might be, but a hint here: try to be as nice as your situation will allow you to be. If the ER is really busy, the staff is likely "feeling the heat!" You might even smile at your nurse or doctor when you ask about the waiting time. That ought to catch us off guard!

Bottom line: the vast majority of ER care providers really want you to receive the best, most expeditious care possible. I know that if we find someone in my own ER that doesn’t have that mindset, he/she will be moving on to another place of employment – hopefully with one of our competitors!

Stay alert and stay safe.

- Dr. Bob

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'Tis the Season - Preventing Colds and Flu

Well, it’s that time of year again – time to begin thinking of the rapidly approaching holidays, of spending time with loved ones, and how to avoid one of the major risks that can put a damper on our celebrations – those nasty respiratory viruses that plague us in the late fall, winter and early spring. Our emergency room census predictably grows every year over the next few months, and much of this is related to the impact that influenza viruses and other respiratory viruses (such as those that cause the “common cold”) have on our population. It is estimated that every year between 5 and 20% of the population in the United States develops clinical illness from influenza (“the flu”), and the numbers are even greater with other upper respiratory viral infections.

So, how best to avoid these viral marauders? First, and foremost, get a flu shot. While this doesn’t provide 100% protection from influenza (it’s about 70-90% effective in healthy adults under the age of 65), it gives each of us the best chance of developing a level of immunity against the viruses that are predicted to be especially problematic over the next several months. Unfortunately, given the speed with which influenza viruses mutate and the amount of time it takes to develop and produce effective vaccines against them, we are left with vaccinating the population with the viruses that are predicted by the experts to be our biggest threat during the upcoming season. “Flu shots,” which contain inactivated (killed) viruses (and, therefore, CANNOT give you the flu!) can be obtained from your primary care physician and from various clinics in your area (including some local pharmacies and even grocery stores that offer the service). It’s best to get your shot sometime in late October to early November to allow your body the time it takes to develop immunity after the vaccination (approximately 2 weeks) before the flu makes its appearance in your area.

It is highly recommended that all immune-suppressed patients and their families get the vaccine as well as anyone at high risk of exposure to the virus (teachers, health care workers, etc.). It is, however, a good idea for all healthy adults who want to avoid the flu to get the vaccine unless they have some specific contraindication to doing so (for example, a history of egg allergy [eggs are used in the production of the vaccine], or a history of adverse reactions to prior vaccines).

The Centers for Disease Control and Prevention recommend that the following people should receive a flu shot:
- People at high risk for complications from the flu, such as:
- Children aged 6 months to 5 years
- Pregnant women
- People 50 years of age and older
- People of any age with certain chronic medical conditions (such as heart or lung disease)
- People who live in nursing homes and other long term care facilities
- People who live with or care for those at high risk for complications from flu, including:
- Household contacts of persons at high risk for complications from the flu (as above)
- Household contacts and out of home caregivers of children less than 6 months of age (i.e., children
too young to be vaccinated)
- Healthcare workers.

There is also a vaccine available for those who are truly “needle phobic” that is administered via a nasal spray. This vaccine is made from live, attenuated (weakened) viruses, and is recommended for healthy people between the ages of 5 and 49 years.

Everyday, sound preventive measures to avoid contracting a respiratory virus include:
- stay well hydrated (we all tend to walk around during our daily lives in a state of relative dehydration).
- get enough sleep (to allow our immune systems to “recharge”) - easier said than done!!
- eat a balanced, healthy diet.
- avoid folks who are spreading their “germs” through coughing, sneezing, etc. It’s perfectly acceptable to ask such individuals to cover their noses and mouths to avoid passing respiratory viruses into the air you are sharing with them.
- wash your hands (or use an alcohol-based hand sanitizer) frequently when out in public (especially after touching door knobs, public phones, shared keyboards, etc.).
- and, very importantly, keep your “unwashed” hands away from your eyes, nose or mouth when out in public. This is the way most respiratory viruses are passed – you get tiny infectious secretions from another person on your hands and then inoculate them into your own mucous membranes.

For more information about influenza and how to avoid it, check out the CDC website at: http://www.cdc.gov/flu/

So, with the approaching holidays, we owe it to ourselves and those loved ones who are looking forward to spending time with us to do all we can to stay healthy and avoid those nasty colds and flu!

Stay alert and stay safe.

- Dr. Bob

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