Prairie Doc® Perspective Week of January 29th, 2023
“It’s time for your checkup”
Andrew Ellsworth, MD
Recently I received a mailing from my clinic reminding me it is time to schedule my annual preventative care physical. Apparently, doctors need to go to the doctor, too, even when they feel fine.
As a primary care physician, one of my passions is preventative care. Preventative care is focused on catching problems before they even start to cause symptoms, catching issues early when they are easier to treat.
Whether you want to call it your annual physical, your yearly checkup, or an annual wellness visit, this appointment gives the time for you and your provider to decide what tests, screenings, and interventions may be done to help you become and stay more healthy. One of the broken aspects of our healthcare system is our focus on problems, playing whack-a-mole, barely getting ahead, and spending too much money way too late on problems that could have been cured a lot sooner, a lot cheaper, with a little bit of effort at prevention.
This visit may go in a variety of ways depending on your age and risk factors. If you are over age 45, you should probably consider your options for colon cancer screening. If you are a woman over age 40, perhaps you should consider breast cancer screening. If you are a man over age 55, perhaps you should consider prostate cancer screening. Any of these screenings may need to start earlier if you have a family history of cancer.
Meanwhile, the visit should probably include a discussion on your mental health, your diet, and your exercise routines. Granted, these discussions take time. If you have a list of problems and symptoms you want to discuss, then perhaps you may need a separate visit to address your concerns, apart from the appointment to cover some of these preventative care topics.
Perhaps this visit will help give you a nudge to quit smoking, and a chance to catch lung cancer early by scheduling a screening CT scan of your lungs. Perhaps this visit will determine that you have high blood pressure or high cholesterol, and interventions could decrease your risk of a heart attack or stroke. Perhaps this visit will catch skin cancer early. Perhaps your provider will identify a medication you do not need anymore, or identify an over-the-counter medication or supplement you should or should not be taking such as vitamin D or aspirin. Are you taking your medications correctly?
The list goes on and on. Pap smears for cervical cancer screening. Reviewing your immunizations and updating a tetanus shot. DEXA scans help determine the strength of your bones and catch osteoporosis, trying to decrease your risk of a fall and a hip fracture.
I suppose I better make that appointment for myself!
Prairie Doc Perspective Week of Jan. 22nd, 2023
“Not all that forgets is dementia”
By Kelly Evans-Hullinger, MD
Frequently, my patients will come to a visit and bring up a major concern: “Doc, I think I might have dementia; my memory seems to be slipping.” They might give examples of having difficulty finding words, forgetting people’s names, or just feeling like their thinking is slower. Many of them know a family member who had dementia, and they are worried.
My first response is to hear their concerns; of course, if a patient is showing early signs of dementia, we want to assess that and do our best to get to a diagnosis for them. What I have found, however, is that often when these concerns are raised, we find things that are not dementia to explain them.
As we age, some symptoms perceived as memory changes are probably within the spectrum of normal. The occasional forgetting or having a delay finding words is a great example of this. More difficulty recalling names is another. This can be normal at any age but tends to happen more frequently as our brains age.
Sometimes patients are noticing real and concerning issues, but through medical evaluation, we find non-dementia reasons for them. The most common reason would be – you guessed it – medications. While many medications can affect cognition especially in older patients, often we can blame drugs with anti-cholinergic properties (even over-the-counter diphenhydramine found in cold, allergy, and sleep medication) and benzodiazepines (usually prescribed for anxiety or sleep). Patients should review their medications, both prescription and over-the-counter, as an early step in evaluating these concerns.
Other common mimics of cognitive change in older patients are depression, anxiety, and sleep disorders. These disorders can cause the brain to be unfocused and distracted which frequently manifests as forgetfulness. Treating the underlying condition effectively will usually improve one’s cognition, so we should look for signs of those when evaluating memory concerns.
Numerous other medical causes can also impair one’s cognition and memory. These include vitamin deficiencies, abnormal electrolytes, infections, or abnormalities in the brain like bleeding, tumors, or hydrocephalus. Further, there are numerous causes of dementia; Alzheimer’s disease being just one. A thorough history, exam, and sometimes labs or imaging might be warranted if true cognitive impairment is present.
To be clear, if you are experiencing symptoms of change in memory, don’t assume it is dementia. Talk with your medical provider; it may be normal or have any of a long list of other causes. Let’s figure it out together.
Prairie Doc® Perspective Week of Jan 15th, 2023
“Extending the Golden Hour”
By Debra Johnston, MD
When I was a young physician, we talked with almost religious zeal about the “Golden Hour.” Early on, this principally focused on the idea that within the first hour after an injury, a patient needed to receive definitive treatment in order to maximize the chances of survival, and recovery. We usually interpreted this to mean that the patient needed to be in the hands of the trauma surgeon before this hour was up. We took ATLS classes so we could make sure that the patient in our emergency room got the best treatment we non-surgeons could provide, until the surgeon could take over.
Of course, in the rural upper midwest, the nearest surgeon, and even the nearest emergency room, might be more than an hour away.
Fortunately for those of us living in more sparsely populated areas, time to the surgeon isn’t the only factor that impacts our chances in an emergency. The care we receive before we get to the hospital matters. In fact, it matters a lot.
Gone are the days of “scoop and run” when the only goal of the first responders was to get the patient to the hospital as fast as possible. As with so many roles in modern society, a first responder today has a more complicated job. They need the training and flexibility to address what they see when they meet their patient. A person who has overdosed on fentanyl needs naltrexone, to reverse the opioid and get them breathing. A person in cardiac arrest needs a shock delivered, to restart their heart. A person who has lost a limb in a car accident needs the bleeding stopped. These things need to be done well before the patient could arrive in an emergency room, even if they were delivered there by helicopter.
Certainly some emergencies require care that is still well beyond what could be provided outside of a hospital. If they can receive it in time, approximately 25% of stroke victims could benefit from clot busting medications. Another 10-15% have strokes that are actually caused by bleeding. It’s a distinction that can’t be made in an ambulance, and the wrong call could be catastrophic.
We all know that the pandemic has radically changed the workforce. Employers around the country are facing a shortage of workers, from fast food to finance. Health care is no different. This includes ambulance services, where the situation is further complicated by the reality that many rural EMS providers rely on volunteer labor. Those volunteers need to know more than just how to drive the ambulance. They need to know how to provide effective interventions, to extend that “Golden Hour.” This particular labor shortage has grave consequences. It is quite literally a matter of life and death.