Hypertension Podcast, Part 2 – Why it Matters

To listen to this podcast, click here.

So how are you doing on your New Years resolutions?  If you are like most people, you probably decided to do something to “take better care of yourself.”  Quitting smoking, exercising, and eating better are always resolved in abundance this time of year. Even though the majority of these won’t be kept, I think these resolutions are good things to do, as there is no chance at all that you can take better care of yourself without living life differently.

But why is it bad to be a smoking couch potato eating donuts?  The answer is really quite simple: it increases your chance of having more pain and earlier death. I am a doctor, so trust me when I say that more pain and early death are things you want to avoid. One of the main ways quitting smoking, exercising, and eating healthier can discourage that pain/death thing is by lowering your blood pressure.

What Is Blood Pressure?

In my last article I explained what blood pressure is and what it means when the nurse blows that thing up around your arm and writes down numbers with a horrified expression. This article will cover the problems that happen when blood pressure is too high and what you can do about it.

First I want to remind you about my sponsor, Audible.com, who will give you a free audiobook for checking out their site at audiblepodcast.com/doctor. I’ll give yet another recommendation at the end of the podcast, so stick around to the end.

What Is High Blood Pressure?

So why does the blood pressure get high in the first place?  It doesn’t do it just out of boredom; hypertension (which is persistent high blood pressure) happens because of bad influences. Bad influences can make people do things they shouldn’t be doing, like getting tattoos in regrettable places. It’s called peer pressure. Well, think of hypertension as the peer pressure of the blood vessels.

What Affects Blood Pressure?

Here are the bad actors that can lead your vessels down the road to perdition (or at least to higher blood pressure):

The Kidneys – kidneys are supposed to filter the blood and maintain the balance of sodium, potassium, and other substances needed to keep things normal. Good kidneys will react to an increased blood pressure by lowering certain hormones in the blood, getting rid of sodium, or making you pee more. But kidneys gone bad are lazy and let blood pressure go up without raising a finger…or nephron.

The Epithelium – I just can’t get through an article without some fancy Latin or Greek word. The epithelium is a thin coating of cells on the inside of the arteries. These cells, it turns out, are very important in determining if arteries will be narrow and contracted or open and relaxed. They react to the sodium, potassium, and other substances, and change the blood pressure accordingly. 

Hormones – these are substances put out by glands–such as the pituitary and adrenal glands–that have effects all over your body. Ideally they are released in response to low pressure, but when hormones go bad they wander around your bloodstream when they shouldn’t be there, when the pressure is normal.

Nerves – Some nerves have the job of relaxing or contracting muscles around blood vessels to keep the blood pressure normal. But some nerves tell the muscles to contract at the wrong time, making the pressure go too high. They’ve got a lot of nerve to do that.

The fact that there are a bunch of different bad influences is what makes treating hypertension so difficult at times; just going after one bad influence may not be enough. You have to get rid of them all in order to get the pressure back under control.

What Causes High Blood Pressure?

So what makes these body parts go bad, causing high blood pressure?  Sometimes it’s not their fault, such as when the kidney gets damaged or a hormone gland fails. But for most people, it’s a combination of bad genes and bad environment that makes these body parts choose their sorry path. Bad genes can cause any or all of the control centers for blood pressure to malfunction.

How Can You Prevent High Blood Pressure?

You can’t do much about bad genes besides griping, but you can do a whole lot to control environment, including the following:

Limit sodium: Eating lots of sodium can put a lot of stress on the kidneys and mess up with the epithelium.

Lose weight: Obesity can change the hormones in the body.

Quit smoking: Smoking messes with the nerves that control the blood pressure.

Limit stress: Stress can mess with hormones and nerves.

What are the Risks of High Blood Pressure?

Often the worst consequences of dumb decisions teenagers make are not felt until much later (like that tattoo you know where). The same thing is true with blood pressure. Long-term elevation of blood pressure puts you at much higher risk of lots of bad things, such as:

  • Kidney damage, and even kidney failure requiring dialysis
  • Plaque build-up in arteries that can cause heart attacks and strokes
  • Aneurysms, which are the ballooning of blood vessels to the point where they can burst. The most significant aneurysms occur in the head and the abdomen.
  • Thickening of the heart muscle, which increases the risk of lethal heart arrhythmias.

There are others, but I think you get the picture. Go after these bad influences early or pay the consequences later.

How Should You Treat High Blood Pressure?

My quick and dirty tips today will tell you what to do about blood pressure.

Tip 1:  Get it Checked Regularly

This is the same tip 1 I gave in my last article, but it is worth repeating. You can have dangerously high blood pressure and not know it. A good pressure to aim for is 120/70.

Tip 2: Look for Other Causes

Looking for kidney or hormone problems (with blood and urine tests) are important when hypertension is first diagnosed. This is especially important if the onset is rapid or at a young age.

Tip 3: Watch Your Diet

The Nutrition Diva didn’t pay me to write this (although she can if she wants to). Diet matters. Keep your weight under control, and if your pressure is even borderline, cut back on sodium and get enough potassium; doing so can keep you from needing medications.

Tip 4: Exercise and Stop Smoking

Exercise not only burns calories and lowers weight, it also lowers pressure by itself. A combination of aerobic exercise and weight training is probably best.

Quitting smoking will not only make you stop smelling so bad, it will lower your blood pressure.

Tip 5: If You Need to, Take Medication

There are a bunch of very effective medications for high blood pressure that are inexpensive and have very few side effects. As long as your blood pressure isn’t extraordinarily high, you certainly should first try the lifestyle changes before going on medication. But you should do what you can to treat hypertension early to avoid the consequences.

The medications that treat hypertension generally attack one of the bad influences I mentioned earlier. Many people have two, three, or even four different reasons for the blood pressure elevation, so it often takes more than one medication to bring it back to normal. As always, you should talk to your doctor and find out why each medication you take is important, as well as what side effects you should look out for.

Any medication is a trade off between negatives and positives. With blood pressure, many people don’t feel bad and so don’t take their medication like they should. That is a really bad idea.

Tip 6: Know When to Panic

Usually high blood pressure is not an immediate risk. The exceptions to this rule are:

  1. When the top number gets above 200 and the bottom number over 110, it’s time to get seen immediately. It actually takes a pressure higher than this to cause panic, but you don’t want to go there.
  2. When high pressure is associated with severe headache or chest pain. These mean you may be sustaining damage to your brain or your heart. You don’t want to go there either.

That’s all I’ve got for blood pressure.

Hypertension Podcast, Part 1 – What is it?

To listen to this podcast, click here.

Chronic high blood pressure, or hypertension, is responsible for a huge amount of death and disease, affecting nearly 60 million people in the US. It is the #1 reason for visits to the doctor and the #1 reason people need prescription drugs. Despite all that attention, blood pressure is poorly understood and is often poorly controlled, resulting in a multitude of problems. It’s a huge topic, and (predictably) impossible for me to cover in a single article, so I will once again split it up into two. Today I’ll try to explain what blood pressure is, and next week I’ll explain the consequences of high blood pressure.

What is Blood Pressure?

Your blood pressure is the pressure used to get the blood to where it is needed. Have you ever gotten into the shower in the morning only to find out that there isn’t any water pressure?  It’s not a fun thing. It not only can make you really grumpy, it can cause those around you to be grumpy about the smell you emanate. Blood pressure is much the same. The bloodstream carries oxygen and food to cells in the body, and it carries away waste products. Insufficient blood flow, then, results in cells suffocating, starving, and not getting rid of potentially toxic waste. That not only makes the cells pretty grumpy, it can kill them.

What is Needed for Good Blood Pressure?

Two things are essential to maintain good blood pressure: good pipes and a good pump. Blood vessels are the pipes in your body. The arteries are like the water pipes, requiring higher pressure to bring the essential fluid to where it is needed. The veins are the pipes that bring back the used blood, much like the sewer system, and don’t require as much pressure. When we talk about blood pressure, we are really talking about the pressure in the arteries.

How are Your Heart and Blood Pressure Related?

The pump in your body is, of course, the heart. The heart is a hollow muscle that squeezes blood out to the body. There are two chambers, called ventricles, that do the pumping:

Right ventricle:  The right ventricle pumps blood to the lungs so it can get oxygen.

Left ventricle: The larger left ventricle pumps blood to the rest of the body.

There are two parts of the heart’s pumping cycle: the part where it relaxes and fills up with blood: called diastole, and the part where it squeezes blood out to the body, called systole.

The two parts of the heart’s pumping cycle are important because they coincide with the two important blood pressure numbers.

Systolic pressure:, Systolic pressure happens when the heart squeezes, and

Diastolic pressure: Diastolic pressure is the lowest pressure in the cycle, which happens when the heart relaxes.

So when a blood pressure cuff is inflated, the highest pressure at which the person listening with the stethoscope hears a “thunk” is the systolic pressure.  The lowest pressure in the cycle, or the diastolic pressure, is signified by when the “thunk” sound goes away.  Here’s why both are important.

What Happens When Systolic Blood Pressure Gets too Low?

The systolic pressure is essential to get blood to the brain. Just like the shower upstairs, a low pressure in the pipes will make the pressure to a person’s upstairs inadequate. It’s pretty important that the brain doesn’t stop functioning, so inadequate blood flow to the brain is not tolerated. If the pressure in the pipes isn’t adequate, the body takes drastic measures to make sure the brain gets enough blood: it passes out. The exchange goes something like this:

Your brain says, “Hey, I need more blood!  I am starving and can’t breathe!”

“I am trying as hard as I can!” the heart responds. I’m even beating faster!”

“It’s not enough,” gasps the brain. “I need food and oxygen. I need it now!”

“I just can’t get blood up there. You are too high up!  Can you make my job easier?” the heart begs.

“No problem” says the brain, and passes out, causing the body to lie on the ground.

“Much better!” responds the heart. Now I can get you all the blood you need.

Pretty cool isn’t it?  You don’t get that kind of drama on the Grammar Girl podcast.

Low systolic blood pressure is an immediate problem; if it gets too low, you can’t live. A high systolic pressure isn’t that big of a deal in the short run, in fact, it’s the diastolic number we focus on more for treatment.  That’s because the diastolic pressure causes more harm in the long-run.

What Should Your Blood Pressure Be?

What’s a good blood pressure?  It depends on the age and size of the individual. Little kids don’t have as much gravity to deal with, so they don’t require as high of a blood pressure. For adults, the normal range for systolic blood pressure (which is the first number in the reading) is between 100 and 130 millimeters of mercury[H3] . Millimeters mercury expresses the amount of pressure in terms of how high it can push a column of mercury – which is a real heavy liquid.  You probably noticed that silver stuff in some blood pressure measuring devices?  That’s mercury.

Systolic pressures in the 90’s are OK as long as there is no fainting or dizziness, but below that is usually the sign of trouble.

The diastolic pressure should ideally be below 80. There is no official number for a low diastolic blood pressure and there are few conditions that cause it to be low without also bringing down the systolic.

Quick and Dirty Tips for Blood Pressure

I’ll stop here now, giving you a few quick and dirty tips regarding your blood pressure. My next article will specifically cover the issue of high blood pressure.

Tip 1: Get your blood pressure checked.

A good goal to shoot for is 120/70. Since high blood pressure doesn’t usually have symptoms, you need to get it checked regularly.

Tip 2:  If you want to know when to worry about your blood pressure, read my next article.

Podcast: When to Worry about Headaches

To listen to this podcast, click here.

A very important skill a doctor must possess is the ability to read minds.  We have to figure out what people are saying when they aren’t saying it.  For example, when a person comes to the office saying, “I’m having chest pain,” they usually are really asking, “am I having a heart attack?”

When Should You Worry About a Headache?

Today’s article will cover another example of this: headaches.  When someone comes to the office with a headache, they are often worried of something more serious: brain tumors, aneurisms, or other scary things.  It’s my job to not only figure out what’s causing the headache, but to reassure people that they are not about to die from something terrible.  This is another installment of my “when to worry” series giving you advice as to when it’s OK to stay home, and when you should run to the doctor.

As I said last week in my “mystery diagnosis” article, the first step in figuring out what’s going on is the story of the symptom:

  •  How bad is the headache?
  • When did it start?
  • Does it come and go or is it constant?
  • When does it happen?
  • Are there any other significant symptoms happening along with the headache?

The answers to these questions are the most important thing in determining if a headache is worth being worried about.

The Headaches You Don’t Need to Worry About

Of the less serious headaches, there are three types that I see the most:

  • migraine,
  • sinus, and
  • tension headaches.

I’ll cover each of them in more detail in future articles, but to understand when to worry about headaches, you first need to know the symptoms of the most common less-serious headaches.

What Are the Symptoms of Migraines?

The main feature that distinguishes a migraine headache is that it is episodic.  Migraines come and go.  When you have one, the pain makes you miserable, but between headaches you feel completely normal.  These episodes last anywhere from an hour to two days, and have some very distinctive features:

•           They often happen on one side of the head (but not always)

•           They are frequently described as being “throbbing”

•           They make a person sensitive to light and sound–you just want to lie in a dark, quiet room.

•           There is pain with movement

•          The pain is sometimes accompanied by nausea and vomiting.

Sometimes migraines are preceded by an “aura,” which is a visual symptom where the person sees flashing lights, squiggly lines, or other visual disturbances.  Auras usually last between 10 and 30 minutes.I can personally vouch for how miserable migraines are.

What Are the Symptoms of a Sinus Headache?

Sinus headaches are sometimes obvious, with nasal congestion and pressure and pain on the front of the face or the forehead. With these symptoms, there isn’t much doubt.  But there are times when the nasal symptoms are not present.  The clues to me that a person has sinus headaches are as follows:

•           Symptoms last for days, weeks, and even months

•           Headache is usually less painful than other headaches

•           Pain is located on the forehead, under the eyes, or behind the eyes

•           Headache pain occurs regularly in the fall and spring

•           Pain is accompanied by a sore throat or cough, especially in the morning.

What Are Symptoms of a Tension Headache?

Muscle tension headaches usually start at the base of the neck and spread to the rest of the head.  I find that the majority of people with tension headaches are not getting a good night’s sleep.  That lack of sleep means their body never has a chance to relax, and so they wake up with tight muscles which get worse over the course of the day.  A person with a tension headache may also have soreness of the jaw from clenching their teeth.

What Serious Medical Conditions Cause Headaches?

So what are the possible bad things that could cause headaches and when should you worry?

Brain tumors: Though brain tumors can cause headache, they often do not.

Aneurisms: Aneurisms, which are areas of blood vessels that blow up like a balloon, can leak and cause a sudden severe headache.  A ruptured aneurism causes profound weakness to parts of the body, and so headaches are rarely the main concern.

Infections: Certain infections, such as influenza, meningitis, and Rocky Mountain spotted fever can also cause bad headaches (along with other symptoms).

When to Worry About Headaches

What are the symptoms that should make you worry?

•           Sudden onset of a severe headache, especially one that awakens you from sleep

•           Onset of regular headaches starting after age 50

•           Severe headache in the morning that is accompanied by vomiting

•           Any significant change to a person’s normal pattern of headache

•           Pain you’d call severe headache or “the worst headache ever”

•           Headache accompanied by confusion or other changes in mental status

•           Headache associated with red eyes

•           Headache following a head injury–especially if the headache gets worse over time

All of these are signs to get your headache checked promptly.

As I have said in the past, if you have any concern, talk to your doctor.  It is your doctor’s job to reassure you of the less-serious problems and possibly find solutions.  There are good treatments for migraines, sinus, and tension headaches.  There is no need to suffer.

 

Podcast: Depression

To listen to this podcast, Click Here.

Last week I explained how anxiety is a medical problem that needs to be taken seriously.  Today I am going to talk about the other head of the emotional dragon: depression. Unlike anxiety, which I described as a feeling of helplessness, depression is more a pervasive feeling of hopelessness.

I want to re-emphasize an important point from last week: there is a big difference between emotions and clinical problems.  Just feeling depressed doesn’t mean you are clinically depressed.  The two important factors that help distinguish between the emotion and clinical depression are duration and severity.

What Is Clinical Depression?

Clinical depression is defined as having five or more of the following symptoms (at least one of which is either depressed mood or loss of interest or pleasure), present most of the day–nearly every day–for a minimum of two consecutive weeks:

•           Feeling of depression

•           Losing interest or pleasure in most or all activities

•           Sleeping too much or not being able to sleep

•           Having a change in appetite or weight

•           Being really slow emotionally or agitated

•           Having low energy

•           Experiencing poor concentration

•           Having thoughts of worthlessness or guilt or recurring thoughts

about death or suicide

A lot of time people know they are depressed, but not always. Sometime people don’t actually feel depressed, so figure they must not be.  But these folks are tired, don’t have any interest in the things that they usually enjoy, they can’t concentrate, and they can’t sleep despite being very fatigued.  That is depression, and it can go undiagnosed for years.

Why Is Depression Often Misdiagnosed?

But how could that be?  There is a certain stigma attached to depression, because in the past, people who were depressed were often falsely considered either too emotionally weak to face the hardness of life or just plain crazy.  That perception was, in part, due to the fact that the old depression medications were very strong and had bad side effects.  The only people who got put on these drugs were those with very bad depression.

How Does Depression Affect People?

There’s a vicious cycle with depression.  Many depressed people don’t sleep, which makes them tired and unfocused.  That in turn can make them more likely to struggle at work or school, causing poor reviews or grades, which makes them more depressed—and so on.

Additionally, a person with depression is generally sad, has no energy, and feels bad about his or herself.  They need to get help, spend time around other people, and find things that make them feel good.  But depressed people often isolate themselves.  It’s hard for them to be around people who ask how they’re doing, and even more difficult when people try to fix their problems.  So as to avoid those situations, the person often feels more depressed and becomes more withdrawn, making matters even worse.  It’s like they’ve painted themselves into a corner.

And if depressed people have feelings of death or suicide, they may isolate themselves even further. Having suicidal thoughts can make depressed people believe they’re crazy or weak. They don’t want others to know about the thoughts and so they isolate themselves even more, making their depression worse.  They may interact with others if they have to, but they don’t connect.

How to Cope with Depression

So what should you do if you think you or a loved one might be depressed? Here are my 5 quick and dirty tips:

Tip# 1: Don’t be ashamed.  Nearly 20% of the US population has an episode of major depression in their lifetime.  It’s a problem that needs help, and that’s just part of being human.

Tip# 2: Talk to your doctor.  Hopefully he or she won’t just throw pills at your problem, but actually figure out whether you are depressed and determine what is the best approach.

Tip# 3: Talk to someone: Talk to a counselor, close friend (especially one who has been depressed in the past), or someone else you trust.  Figuring out what is beneath the depression is a big part of overcoming it.  Counselors don’t wave a magic wand over you, they work with you to figure out what core struggles or past trauma are causing your depression.  It takes a lot of work on your part to really make progress in this area.

Tip# 4: Consider medications.  I see medications for depression as being like supports you would put up on a wall that’s falling down.  They keep the wall from falling and they allow you to work to fix the wall, but they are not a solution.  Medications work wonderfully, but should always be only part of the solution.

Tip# 5: Get help immediately if you think you or your loved one is at risk of self harm, suicide, or physically harming others.  It’s hard to see straight when you are in the depths of despair.

Let me finish with a statement to those thinking about killing themselves.  A lot of people who are depressed think they are a burden on their friends and family.  They rationalize that killing themselves will free their loved ones from that burden.  That is a lie.  There is absolutely nothing worse you could do to your loved ones than to kill yourself.  Suicides wreak havoc in the lives of those close to the person.  Suicide is never a selfless act.  If you have thoughts of suicide–of really going through with killing yourself, not just fleeting thoughts–remind yourself of the pain you would put your loved ones through and seek help immediately.

Podcast: Anxiety

To listen to this podcast, click here.

The next two articles will cover an area that takes up a lot of my time in practice: anxiety and depression.  These two problems are not just mental health issues; their presence can also greatly affect a person’s physical health.  Today I’ll focus on anxiety, although I will start out with some general principles around both of these conditions.

When discussing anxiety and depression, we first have to define terms because both words represent emotions and medical conditions.  Anxiety, the emotion, is a normal part of life.  If you see flashing lights in your rear-view mirror, you get anxious.  Simply feeling anxious is not cause for medical concern.  The same is true for the emotion in depression–sadness–which happens as a normal part of life.

Clinical anxiety and depression are not the same as the emotions, although the emotions are present.  These are real medical problems that have a big impact on your life.  Two things separate emotional states and clinical conditions: duration and severity.  In order to “officially” diagnose clinical anxiety and depression, symptoms have to last more than three months and have a significant impact on the daily function of life (although in reality, they are often diagnosed before 3 months).

I’m going to leave depression for next week and focus on anxiety now.

What Is Anxiety?

So what is anxiety?  Anxiety, the emotion, is a feeling of powerlessness or helplessness.  If you had a magic button in your car that made the police car behind you disappear, the presence of those lights wouldn’t be so traumatic.  It’s the inability to control things we think may hurt us that makes us anxious.  When clinical anxiety exists, it makes life feel out of control…which creates more anxiety. That is perhaps the hardest thing about clinical anxiety: you get anxious about being anxious.

How Is OCD Related to Anxiety?

But anxiety takes many forms, many of which don’t look like anxiety.  When a person feels out of control, they often find ways to compensate.  A good example of this is obsessive-compulsive disorder, or OCD.  Many people with OCD have something in their life–past or present–that they want to control but can’t.  Perhaps they were abused as a child, or perhaps they’ve lost spouse or child.  Their reaction is to control something that is in their power–like keeping their house clean, washing their hands, or locking the door.  That attempt to control things becomes a compulsion–something they can’t stop from doing.

What Is Generalized-Anxiety Disorder?

[Big anxiety–anxiety that casts a long shadow in your life–usually needs professional help.]

Sometimes anxiety is a non-specific feeling of worry or dread, such as with generalized anxiety disorder.  Anxiety can be very specific to situations, such as with phobias including fear of bugs, snakes, public speaking, heights, or water.  I am not talking about people who don’t like bugs or snakes, I am talking about people who won’t leave their house or can’t sleep because of these fears.  Sometimes the anxiety revolves around relationships, as is the case with social anxiety disorder, and sometimes the symptoms come in episodic flares, like with panic disorder.  Finally, some people escape their anxiety using alcohol, drugs, or other addictions.  That list is by no means exhaustive; the bottom line with these behaviors is that they are a reaction to the person’s vulnerability or helplessness.

What Causes Anxiety?

Like most illnesses, anxiety disorders are a mix of heredity and environment.  Having a family member with clinical anxiety doesn’t guarantee you will have it, but it will make you more prone to trauma that can trigger clinical anxiety.  But please hear me on an important point: anxiety has a reason.  It’s not moral weakness or a lack of faith that makes people struggle. Unfortunately, people around those with clinical anxiety don’t know that, and often chide them to “just don’t worry so much.”  That adds the emotion of shame to the struggle with anxiety, and it is unnecessary.  People with anxiety disorders don’t wake up and decide that they will be anxious.  They would love to stop, but can’t.

How to Cope with Anxiety

So what can be done about anxiety?  Here are my Quick and Dirty Tips for dealing with anxiety.

Tip #1: Don’t feel ashamed. I wouldn’t blame you for bleeding if I threw a brick at you, and most people dealing with anxiety have had emotional bricks thrown their way.

Tip #2: Look for root causes. Usually there is something from the past that hasn’t been dealt with that you are either trying to escape from or resolve.  Understanding why you feel the way you do helps a lot in trying to overcome it.

Tip #3: Talk to someone. If the anxiety is not too big, talking to a friend, family member, or religious leader might help.  But big anxiety–anxiety that casts a long shadow in your life–usually needs professional help.  Find a counselor who has been trained to treat anxiety.  You shouldn’t be ashamed for seeking help; it’s a much worse thing to run from your problems.

Tip#4: Take medications if needed.  There are two main kinds of medications for anxiety: ones that last a short time, and ones that you take every day.  The shorter-acting medications are usually medications like Valium or Xanax, which can be addictive if used too often.  If you need one of these medications more that a few times a week, you should probably consider getting on a preventive daily medication, like Paxil or Zoloft.   These medications don’t fix the root problems causing your anxiety, but they do steady your emotions enough that you can face those bigger anxieties that lurk in the shadows.

I’ll stop here for now.  There is a whole lot more I could say, but I just wanted to give an overview.  Next week I’ll cover anxiety’s cousin: depression.

Podcast: Leg Cramps

To listen to this podcast, click here.

Cramps can happen anywhere in the leg, but this article will focus on those leg cramps that happen in the calves.  So wouldn’t that make them charlie calves?  I don’t know.  I guess I’ll have to ask Grammar Girl.

What Is a Cramp?

A cramp is the tightening of a muscle into the contracted state.  Muscles have two states: relaxed and contracted.  A muscle is relaxed when all of the fibers within the muscle are elongated.  When the muscle does its job, calcium goes into the muscle cells and sodium rushes out.  Doing so causes the fibers to shorten and the muscle to pull–doing it’s work.

That is not a problem in the short term, when the muscle is doing what it’s supposed to do.  But when a muscle stays contracted, a sharp and intense pain occurs.

What Causes Cramps?

Why do cramps occur?  One reason is a decreased supply of oxygen.  If you’ve ever gotten a “stitch in the side” when exercising, you’ve experienced this phenomenon.  When the work of the muscle outstrips the flow of blood and supply of oxygen, the muscles cramp up.  That doesn’t happen under normal circumstances in the leg–even with significant exertion.  But when the blood supply to the leg muscles is compromised, specifically from a build-up of cholesterol plaques in the arteries, the muscles will cramp.  The cramping of the calves during exercise is something called claudication, which heralds the presence of peripheral artery disease, or PAD.  I’ll talk more about this later.

What Causes Leg Cramps?

[In general, cramps are a sign that things are out of balance.]

Another, less serious, reason for leg cramps is that the electrolytes are out of balance.  Electrolytes are the chemicals that help the muscle contract, the main ones being sodium, potassium, and calcium.  If any of these gets out of whack, the muscle doesn’t work like it should, resulting in cramping.  This electrolyte imbalance is often the cause of those painful cramps that wake you up at night.

What Causes an Electrolyte Imbalance?

What causes these electrolytes to get messed up?  There are a number of things that can lead to this:

Overheating and sweating: Overheating and sweating a lot will cause the body to lose sodium, potassium, and magnesium.

Medications: Certain medications can also cause the body to lose these chemicals, the most common of which is the water pill, or diuretic.

Medical problems: Finally, there are medical problems that can cause the balance of these chemicals in the blood to go awry.

Other Causes of Leg Cramps

In addition to claudication and electrolyte imbalance, the last of the major causes of leg cramps are medications.  Besides the aforementioned diuretics, other medications, such as blood pressure and cholesterol drugs, can make the muscles ache and even cramp up.

Sometimes the cramps are a mystery.  A good portion of the time, leg cramps at night don’t have a clear cause.  That makes their treatment more challenging (and it drives both doctor and patient a little crazy).

When Should You Worry About Leg Cramps?

When should you worry about leg cramps?  In general, cramps are a sign that things are out of balance.  If you have pain in your legs whenever you walk and the pain gets better after resting, tell your doctor.  That might be a sign of claudication and the narrowing of the blood vessels in the legs could be a sign that you have narrowing of other blood vessels in your body, such as those supplying the heart and brain.  People with claudication are at a significantly increased risk of having a heart attack.

Leg cramps that begin after you’ve started a medication are also concerning.  Sometimes the medications could be causing a decrease in blood flow to the legs, and sometimes (as is the case with certain cholesterol medications) they could be damaging the muscles.  Technically, the pain from cholesterol medications is not a crampy pain, but generalized aches–though everyone is different.

What Should You Do About Leg Cramps?

So what should you do about leg cramps?  For those people who have seen their doctor and have had more serious problems ruled out, leg cramps can still be a great nuisance, and treating them can be a challenge (which in doctor speak means that we can’t always fix the problem).  Here are some treatments for leg cramps that have worked in my practice:

Potassium and magnesium – Even if lab tests are negative, sometimes taking potassium and magnesium can improve the symptoms.  Magnesium supplements are safe (although they tend to loosen the bowels some), but potassium supplements shouldn’t be taken without some supervision by your doctor.

Cut back on alcohol and caffeine – Both of these can cause mild dehydration, which can make muscle cramps more likely.

Stretches –  Leg stretches before bedtime can improve symptoms.

Medications – Quinine is an old medication that works really well.  The problem is that it not only interacts with other medications, but it can itself have significant toxicity too.  It’s not available on the market for leg cramps, but some people find drinking a little tonic water, which contains quinine, can help. Diphenhydramine, or Benadryl taken at bedtime can help as well. When all else fails, talk to your doctor.  There are some prescription medications that can help as well.

Finally, I want to mention that leg cramps are not the same thing as restless leg syndrome, which is not as painful but equally irritating.  I’ll cover that and PAD in a future article.

Catch you next time!  Stay Healthy!

Origin of the term Charlie Horse

I also like the entry in Wikipedia, which gives different culture’s terms for a Charlie Horse:

In the German-speaking world, it is commonly known as a Pferdekuss (horse’s kiss), while in Norway it is referred to as a lårhøne (thigh hen), in Sweden as a lårkaka (thigh cake), in the Netherlands as an ijsbeen (ice leg) and in France as a béquille (crutch). In Portugal, it is known as a paralítica, roughly translated to “paralyzer”. In Japan it is known as komuragaeri (こむら返り?), which is literally “cramp in the calf”. In northeastern Italy, it is commonly called a lopez, while in the northwest it is called vecchia (old woman) or dura (“hard one” or “tough one”); in the south of the country, instead, it is called morso di ciuccio (donkey bite). In some areas of central Italy, it is called opossum.

 

Podcast: Hospice

To listen to this podcast, click here.

Today’s podcast is about a subject people like to avoid: dying.  Yes, most people try to avoid dying and also don’t want to talk about it.  Even doctors feel uncomfortable talking about death.  But avoiding thinking or talking about death can be very costly and can lead to a whole lot of unnecessary suffering and pain.  I believe that this may be the most important article I’ve done so far, and recommend you share it with your family members.

As a primary care physician, I’ve been alongside of a lot of dying people.  Although it’s certainly hard to see people go through pain and loss, it is also an incredible opportunity to be there when help is most needed.  Some of the most moving times I’ve been privileged to share with people comes during their last days.

Why Talking About Death is Important

Sometimes life’s end comes suddenly and unexpectedly.  But much of the time, people have time to prepare for death.  The problem is, despite obvious clues that a person’s life is ending, doctors, family, and the patient himself too often do little to prepare.  One of the most underused resources that can greatly improve a person’s last days is hospice care.

What Is Hospice?

Hospice, also called palliative care, is end-of-life care, which specifically focuses on people who have 6 months or less to live.  The goal of hospice is to improve the quality of life for both patients and their families, by aggressively treating pain and offering resources that are not available in other circumstances.  A crucial fact that most people (even doctors) don’t know is that hospice care is 100% covered by Medicare, and by most private insurance plans as well.

What Are the Advantages of Hospice?

There are many advantages to hospice, including:

Complete care: Hospice care includes comprehensive care by a team including doctors, nurses, and social workers. It also provides access to help twenty-four hours per day, seven days per week.

Home visits: Insurance severely limits the availability of home nurse-visits, but not when the visits fall under hospice care.

Fewer expenses: Hospice care leads to a reduction in out-of-pocket expenses for medications and medical equipment.

Respite care: Most hospice care is done in the home, but brief inpatient care is offered by many hospices to take stress off of family members.

The key is that hospice takes the burden off of patients and family members so they can focus on each other instead of on medical care.  This is one of the most important times of a person’s life, and hospice allows them to focus on what’s most important instead of figuring out how to get care.

The Goal of Hospice

[Hospice takes the burden off of patients and family members so they can focus on each other instead of on medical care.]

Most of my job involves keeping my patients healthy, but there comes a time in most people’s lives when the focus needs to change.  We’ve got to stop thinking about preventing colon cancer and reducing cholesterol, and instead focus on reducing pain and maximizing the number of good days a person has.  People are afraid that getting hospice involved is the same as giving up.  It’s not.  I explain hospice this way: the focus is no longer on the next three years; it’s on the next three months, three weeks, or three days.  The goal is to make those months, weeks, and days as good as possible.

Why People Don’t Like to Talk About Hospice

But hospice is an admission that the end is near, and that scares a lot of people.  The sad fact is that most people wait far too long before getting hospice care, which means a much bigger burden on the family and much more suffering for the patient.  I think one of the main reasons people don’t get hospice is that doctors are afraid to bring it up.  The truth is that it’s difficult to tell when someone has six months to live.  Some people who you think will live for a year, only last a month, whereas others far outlive your expectations.  But a friend of mine who is a specialist in palliative care explained it this way: if you wouldn’t be surprised if the person died in the next six months, then the person probably qualifies for hospice.

And hospice doesn’t just focus on the elderly or people with cancer. Anyone with an approximate life-expectancy of six months or less, regardless of age or disease, qualifies for hospice.  So what if a person lives beyond the 6 months?  That’s actually fairly common, and it’s perfectly fine.  As long as the person reasonably qualifies up front, the care will be covered as long as the hospice deems it appropriate.  I once had a patient survive for three years on hospice.

What Are the Disadvantages of Hospice?

So what are the disadvantages?  The main thing is that the scope of care is limited.  Hospitalizations are discouraged, as are any treatments that are solely for the extension of life.  Visits to the intensive care unit, or aggressive treatments of cancer can prolong life a little more, but they often greatly reduce the quality of that life.  Limiting the scope of care to services that improve quality of life allows a person to die with dignity at home, instead of in a hospital hooked up to machines and tubes.

So here is probably the most important quick and dirty tip I’ve given so far: if you think you or a loved one may qualify for hospice, talk to your doctor right away and ask for an evaluation.  The hospice team will come out and make an assessment. They will describe the services they offer and address fears you may have.  Don’t wait for your doctor to bring it up.  And to those doctors who read this article, I give this tip: don’t wait too long.  Take advantage of the wonderful resource of hospice care.  People need to be given the opportunity to die at home surrounded by their loved ones.   Doing so is possibly the best thing you can do for someone.

That’s it for today’s topic.  I hope it was helpful.

Podcast: Warts

To listen to this podcast, click here.

Last week I wrote about when to worry about abdominal pain, a condition that can kill.  This week’s article is not about a killer; in fact, it doesn’t even hurt very much.  It just bugs people.  It’s like that annoying relative who won’t leave your home.  Today’s subject is warts and how you can get rid of them.

What Are Warts?

The medical name for the most common kind of wart betrays the general attitude toward them: it’s called verruca vulgaris.  Yes, that is latin and it translates as vulgar wart.  Really, warts are just bumps of dead skin tissue covering a center infected by a virus.  What’s so terrible about that?  I’m not sure, but people don’t like them and so frequently ask me to rid them of this vulgar plague.

What Causes Warts?

Most warts are caused by the human papilloma virus, or HPV, which is highly contagious and transmitted through direct contact with other people with warts, or with things those warty folks have touched.  So even though the whole kissing a toad causing a wart is a myth, it is technically possible–if someone rubs their wart on a toad before you kiss it.  That doesn’t happen very often, though.

 Viruses and Warts

Viruses like HPV are divided up into strains, which are small genetic variants of the same virus.  HPV comes in over 150 strains, with certain ones having a predilection for certain parts of the body.  A few of the strains infect only the skin in the genital tract.  I’ll cover these in another article, but my statement at the beginning about warts not being killers does not apply to genital warts, as they are a direct cause of cervical cancer in women.

Where Can You Get Warts?

[There is one more wart treatment that has gained notoriety and has caused controversy: duct tape.]

Warts occur most commonly in children and young adults, and can be found nearly anywhere on the body, but the hands, feet, knees, and elbows are the places I see them the most.  Warts on the bottom of the foot are known as plantar warts.  Many folks call them “planter’s warts,” as if you get them from planting things or from peanuts, but that is incorrect.  The bottom of the foot is called the plantar surface, hence the name plantar warts.  People don’t generally get sick or die from plantar warts, although people with diabetes should always be careful with their feet.  The reason these warts are a problem because you have to walk on them, and that hurts.

For some reason, people who handle poultry and fish (but not toads) and people with weaker immune systems are more likely to get warts.  After contact with the virus, the wart won’t show up for 2-6 months, and then it can last for years.

How Can You Get Rid Of Warts?

The majority of warts go away on their own without treatment, but many people still opt to get treated.  There are a number of wart treatments that have varying degrees of success.  I’ll tell you about the most common ones:

Freezing – Warts can be frozen using liquid nitrogen.  That causes local frostbite in the area of the wart, causing direct destruction to the wart as well as alerting the immune system to the presence of HPV in the skin.  It may take several rounds of freezing to totally get rid of the wart.

Salicylic acid – This is the liquid preparation you can buy over-the-counter.  It works in the same way freezing does, causing chemical destruction as well as recruiting the immune system to get rid of the virus.  For both freezing and salicylic acid, first pare away the dead skin on top of the wart to expose the raw skin underneath.  You can do this with a file, an emery board, or a pumice stone after taking a shower or bath, which serves to soften the skin.

Immune therapy – Unlike the first two treatments, which can be done at home, immune therapy is done in the office.  It’s done by injecting a small amount of an immune-reaction causing substance underneath the wart. This too brings the HPV to the attention of the immune system and is quite effective in getting rid of warts.  The most common substance used is an extract from candida, a yeast found on the skin.

More extreme treatments – Dermatologists will use lasers, apply caustic agents, and surgically remove large warts.  All of that is safe, but these wart treatments do cause pain and require a period of recovery.  With any treatments for warts, you have to ask yourself if the treatment is worse than the disease.  People will go to great lengths to get rid of something that causes no harm.

Does Duct Tape Get Rid of Warts?

There is one more wart treatment that has gained notoriety and has caused controversy: duct tape.  In 2002, a paper was published that suggested using silver duct tape on warts was actually significantly more effective than freezing them.  News of this spread, and soon many were wearing silver shiny patches on their skin.  The treatment goes as follows:

  1. Cover the wart with duct tape and leave in place for 6 days.
  2. Remove the tape on the 7th day, soaking the area of the wart and removing dead skin with a pumice stone or emery board.
  3. Leave the duct tape off for the whole 7th day.
  4. Reapply for another 6 days, repeating the cycle until the wart is gone.

This method of wart removal was cheap, easy, and appealed to us men who are genetically predisposed to a belief that duct tape can fix anything.  Subsequent studies, however, were not able to verify this effectiveness, and so the validity was called into question (obviously by a bunch of women).  Yet there were differences in the duct tape used in the follow-up studies, as the tape used had a different type of adhesive and so may have negated the positive effect.

All in all, the treatment with duct tape is worth trying, although I suggest using a skin-colored tape, or covering the skin with a bandage.  By the way, duct tape is also quite useful in dealing with that annoying relative that won’t leave.

No charge for that last tip.

 

Podcast: When to Worry About Abdominal Pain

To listen to this podcast, click here.

In previous podcasts I’ve given mystery symptoms and shown how doctors make the diagnosis.  But something needs to happen before the doctor can make a diagnosis: the patient has to come in.  Deciding when to worry about symptoms is one of the hardest decisions.  One one side, you don’t want to feel foolish coming in for something small; on the other side, you don’t want sit at home with a serious problem.

So I am starting a series called, “When to Worry….”  I’ll try to give you guidelines as to when a symptom is worrisome, and when it is OK to wait.  Let me emphasize, however, that this is general advice that doesn’t apply to all circumstances.  It is far better to be seen for a problem that ends up not being serious than to sit at home with a dangerous condition.

It’s two in the morning and you wake up with pain in your abdomen, or perhaps it is your child that wakes you up with a stomach ache.  When should you seek immediate help, when should you make a doctor’s appointment, and when is it OK to wait?

Anatomy of the Abdomen

The abdomen is divided up into five sections.  The location of the pain can sometimes help in determining whether pain is worrisome or not.  Here are the main regions:

Upper right quadrant: The right upper quadrant contains the liver and gallbladder, which are protected by the lower right part of the ribcage.  The large intestine, or colon, also spends a little time in this section.

Upper left quadrant: The left upper quadrant contains part of the stomach and the spleen.  The colon spends time here as well.

Upper middle section: Between these two sections, in the upper middle of the abdomen, is a section known as the epigastrium.  This is an important section because it contains the most of the stomach, part of the small intestine, and the pancreas–all of which can cause pain.

Right lower quadrant: This quadrant contains more colon and the last part of the  small intestine, where the appendix resides.  In women, one of the ovaries is in this section.

Lower left quadrant: The other ovary lives in the left lower quadrant, along with the last part of the colon.

What Causes Stomach Pain?

There are a few common problems that are caused by certain troublemakers in the abdomen.  I’ll give you the list of the “abdomen’s most wanted,” and where they tend to hang out.

The appendix: This is a small tube that can become infected and cause a dangerous problem.  Appendicitis pain usually starts around the naval, but then settles in the right lower quadrant.  This is true the majority of time, but not all the time.  More on this later.

The gallbladder: This organ is a sack that collects a digestive juice called bile.  It can get infected or get stones, and usually causes pain in the right upper quadrant.

The stomach and first part of the small intestine: Ulcers can form in these organs, causing bleeding, pain, and occasionally a perforation, leaking stomach acid into the abdominal cavity.  Ulcers usually cause pain in the middle above the belly button.

The pancreas: This organ puts out strong digestive juices.  These juices are so strong that they can actually digest abdominal organs if the juice gets in the wrong place.

The colon: Pain from the colon can occur at nearly any place in the abdomen, although the most serious condition, an infection called diverticulitis usually causes pain in the left lower quadrant.

When Should You Worry About Stomach Pain?

[It’s better to get checked out by a doctor for nothing than to stay at home with something more serious.]

Location is important, but the nature of the pain itself is even more so.  Here are some of the things that make stomach pain more worrisome:

Severity: Pain that wakes you up out of your sleep or stops you in your tracks is always worth worrying about.

Persistence: Pain that’s continuous or lasting more than 10 minutes is more worrisome than intermittent, brief pain.

Tenderness:  Doctors use the term tenderness to signify pain that results when the body part is pressed upon.  From a patient’s perspective, tenderness is when movement makes the pain worse.

Loss of appetite: When a serious problem happens in the abdomen, the body shuts down digestion.  Things stop moving through the digestive tract and the person feels nauseated and doesn’t want to eat.  It’s rare for someone with appendicitis, for example, to want to eat anything.

Vomiting: The extreme of a shut-down digestive tract happens with vomiting, which is why vomiting can sometimes be cause for concern.

Blood in bowel movements: Painless bleeding is not as big of a concern, as it’s usually from hemorrhoids.  But bleeding along with abdominal pain is a bigger concern.

Melena: The word melena describes black, tarry bowel movements.  That is a sign of bleeding from the gastrointestinal tract that leads from the stomach.  The acid in the stomach changes the blood from red to black and tarry.  If something is causing enough bleeding to cause melena, it is usually something bad, like a bleeding ulcer.  Melena is serious, and people with it should go directly to the emergency room.  That is true even if there is no pain.

Dizziness: If you are getting dizzy or light-headed with abdominal pain, it may mean your blood pressure is dropping.  Get seen right away for this.

When Don’t You Need to Worry About Stomach Pain?

The reassuring signs are the flip-side of the worrisome signs:

•           Mild pain

•           Intermittent pain

•           Pain isn’t worse with pressing or movement

•          Pain isn’t associated with a lack of appetite

•           Pain doesn’t interfere with regular activity

Furthermore, the passage of stool and gas shows that the digestive tract is working, which is also reassuring.  That’s why surgeons ask people if they are passing gas after they perform abdominal surgery.

The Quick and Dirty Tip

The bottom line, of course, is that it’s better to get checked out by a doctor for nothing than to stay at home with something more serious.