Posts Tagged ‘vitamin D’

A friend’s death 2: massage

March 13, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

Physician is a large part of my identity. I observe people wherever I go, I note physical findings.  A stiff gait, poor arm swinging, and a face that doesn’t move normally indicates Parkinson’s disease, even before the tremor.  I call that airport neurology.

In any social gathering, people will come to me for medical advice, and I don’t even try to dodge. Lack of a state medical license limits what I can do out-of-state.  I listen sagely and say the 7 things the doctor always says: nicotine, caffeine, alcohol, overweight, exercise, sleep, and seatbelts.  And, these days, I recommend vitamin D.

None of those who gathered for my friend’s service uses nicotine. Most caffeine users expressed a willingness to taper down to zero and stay caffeine free for two weeks as long as they could do a full dose rechallenge.  Almost all get regular exercise and about half do yoga.  None are overweight, all have conscientious diets, and most do not sleep well.

In our college years, Bob and I hung out in a social group where we did a lot of back rubs; one of us went on to become a licensed massage therapist.

I can feel other people’s pain by touch. Such a talent has a surprisingly wide distribution: almost all massage therapists and chiropractors.  Bob taught me a good deal about finding hot spots in other people’s backs, and what to do about those spots.

I remember early in our friendship, as he leafed through a Playboy magazine, he said something like, “If she doesn’t get that T6 adjusted she’s going to get an ulcer.” I looked, he pointed at the photo of a good-looking young woman’s naked back.  “You look for the ridge-valley sequence,” he said, “And where there’s an interruption, there’s a problem.”

He taught me how to adjust the spine, from the critical vertebra at the base of the skull to the place where the pelvis joins the lumbar spine.

I shudder now to think that I acquired the tools before learning when to use and when not to use them, comparable to giving a 3rd grader a chain saw.  But acquire those tools I did, and when I took the osteopathic manipulative therapy course in med school I had close to a decade of experience.

Over the last 30 years I developed a routine for relaxing the muscles in the upper back and neck, and for most the routine takes 3 minutes. A couple of years ago, at a clinic I will not name, a teenager’s neck muscles (trapezii and paracervicals) melted when I touched them in the initial tactile scouting expedition, cutting 2 minutes and 50 seconds off the routine.

This last weekend, the people I massaged, Bob’s friends and family, relaxed very easily. When I demonstrated the way to relax the muscles without help, I had an audience of half a dozen.

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Colleagues, vitamin D, and statin myopathy

June 20, 2016

There once was a doc from Manhattan

One day we just fell to chattin’

I asked, “What would it take

Besides a muscular ache

To get someone off of a statin?”

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

 

Merkin’s Law states that any patient given a high enough dose of a statin for a long enough time will eventually hurt so badly exercise becomes impossible.

We call the drugs statins now because the generic names all end with those two syllables, but when they first came out we called them HMG coA reductase inhibitors. We used those drugs for years to lower cholesterol, in the hopes of decreasing risk of heart attack and stroke.

More than 20 years ago, though, a cynical doctor at the back of a lecture hall questioned the utility of that class of drugs if we got no net benefit in all-cause mortality. It seems, he said, that for every life saved from heart attack or stroke, one was lost to homicide, suicide, car accidents or respiratory infections.  The crowd laughed at the litany of diseases.  A year later, at the same Continuing Medical Education event, we chuckled when the same scene played, and a year after that, nobody laughed.  Aggressive drug company marketing fueled the cholesterol hysteria but I never developed a passion for treating cholesterol numbers.

My wife, after 3 years of statin therapy, over the course of 5 days developed such severe aches that her Tae Kwon Do class missed her black belt till she quit the med and recovered. Such circumstances did not endear that bunch of drugs to my heart.

Still, in context, I have the obligation to give my patients standard of care. I tell them about diet and exercise almost to the point of nagging, then I start the statin, and I warn them about side effects.

In the last two years, we have gotten convincing evidence that high-dose statins, regardless of cholesterol numbers, improve the outlook for those at high risk of heart attack and stroke.

Still if a statin patient hurts for no good reason, I tell them to stop the med, but I also test the blood for creatine phosphokinase (abbreviated to CPK or CK).

I outlined my personal algorithm to my colleague, and described my strategy of stop and rechallenge, and, if need be, use of coenzyme Q10.

He told me, gently, that coQ10 does no good, but switching to a lipid soluble statin does.

I found the discussion so constructive I went online, and found, to my chagrin, that he was right, and my past experience with coQ10 relied on the placebo effect.

I stuck my head in his office, and told him he was right. But I also told him I learned to check the thyroid and the vitamin D in those cases.  He looked at me with the same amazement I felt when I’d read about lipid-soluble statins.

We both emerged from the experience better doctors.

The root that Mayo missed: whittling down the med list

May 18, 2015

A three-pack of vitamin deficiencies

February 1, 2011

A folic acid deficiency,

With a vitamin B12 insufficiency

     Gave fatigue and malaise

     And without the sun’s rays

Led to calcium metabolism inefficiency

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

Vitamin D deficiency runs rampant here because Barrow doesn’t receive any useable sunlight ten months a year.  UV irradiation raises the level in milk and dairy products, but not enough for most people.  Missaghak, fermented seal oil, has a lot, but for various reasons the people here don’t consume as much as they used to.

Without adequate vitamin D, a body can’t absorb or utilize calcium properly, and mobilizes the mineral from bone.  While the bones weaken, the layers of bone that have lost matrix start to swell, and the vitamin D deficient patient, in addition to feeling lousy, hurts all over. 

Doctors debate about vitamin D deficiency; some assert that it garners too much attention, but even the worst naysayer would agree a level in the single digits merits treatment.

Vitamin B12 comes only from animals or things resembling animals; human beings don’t make it and have to ingest it.  Most people in the US get enough B12 from eating meat, eggs, and milk.  Strict vegetarians (such as Hindus) in third world countries get enough insect contamination in their grains to fulfill their B12 needs.

A strict vegetarian, who uses no meat, fish, poultry, leather, honey, eggs, milk, or soap exists on a higher moral plane than the rest of us, but has, at most, a ten-year life expectancy.  Vitamin B12 deficiency would start showing itself at five years, and would progress to an ugly death five years later.

As people age, they can lose their ability to absorb vitamin B12, which leads to deficiency.

As a child, I heard the phrase pernicious anemia but I didn’t know what it meant; at the time the term circulated enough that most people had heard it.  It warranted the name pernicious because the patient always died.  With the discovery of vitamin B12, and its cofactor folic acid, the problem found a treatment.  Most people in the twenty-first century have never heard of pernicious anemia.

Folic acid works with vitamin B12 to repair nerve cells and blood-forming tissue.  An excess of folic acid can cover early deficiency of vitamin B12, allowing irreversible neurologic damage without any sign of anemia.  Thus, by law, over-the-counter vitamins can contain no more than 400 micrograms of folic acid per pill.

The first sign of folic acid or B12 deficiency is just plain not feeling good.

Folic acid deficiency happens rarely; the vitamin occurs widely in nature, and people don’t lose their ability to absorb it.  Though I check often, I have seen fewer than ten cases in the last three decades.

I got to sit down with a patient (who gave me permission to write this information) and say, “I can help you, I can make you feel better.  You have three vitamin deficiencies.”

Slightly outside the parking lot medicine

September 14, 2010

When a child has deficient attention

This is my diagnostic contention:

     The least sufficiency

     Would be to test for deficiency

Of iron and vitamins that I’ll mention

This evening I went to another town outside my thirty-mile non-compete limit with a friend who teaches Tae Kwon Do. 

I could write a great deal about martial arts, and in fact I made Tae Kwon Do the subject of a novel (not in print, I am hoping to get an agent).  In brief, martial arts communities have an important place in our cities and towns.

I sat next to the mother of two of the students, a male age eight and a female age ten.  She gave me permission to write about the following information.

The eight year old had a medically complicated first two weeks, and since then he’s been a behavioral problem at home, but not in school.

I asked if he were on medication; the mother told me no.  I told her that a medication list with nothing on it is a good start.

Then I said that I never give the diagnosis of ADD or ADHD until I have the following normal lab work:  complete blood count, erythrocyte sedimentation rate, thyroid stimulating hormone, 25 hydroxy vitamin D, lead level, chemistry 14 panel, ferritin, vitamin B12, and folic acid.

I have never once seen lead poisoning, and I’ve been looking hard for thirty years.  But I’ve seen a lot of behavioral problems from iron deficiency, which has much biochemistry in common with lead poisoning, hangovers, and porphyria (a very rare blood disease).

I’ve also seen ADHD get a lot better with vitamin B12 replacement; my youngest B12 deficient patient was eleven years old.  Some of my ADHD patients improved when the vitamin D deficiency resolved.

The few children I’ve seen with underactive thyroids all had behavioral problems, which either improved greatly or disappeared when they had adequate thyroid supplementation.

I’m not a big fan of medication for ADHD.  The disease runs a spectrum from not so bad to disabling, and at every level treatment involves varying combinations of coping strategies or medications.  Pills alone won’t help nearly as much as pills and skills.  A combination of an alarm watch that goes off every fifteen minutes, a continuously updated list, and a Palm or other PDA can go a long way to obviating a pharmacologic strategy.

If easy distractibility makes the diagnosis of ADD, then I have the disease.  I suppose in comparison to other people my age I’m hyperactive.  I have made a lifelong habit of avoiding cross talk and multiple conversations, and I will be the first to admit that I don’t multitask well.

I’m a Family Practitioner from Sioux City, Iowa.  In the year that my 30-mile non-compete clause ticks out I’m having a lot of adventures.  If you want to comment on a post, click on the title.

More than you wanted to know about pernicious anemia, vitamin B12, folic acid, and rheumatoid arthritis

July 9, 2010

 

I think meat is nutritious

You might even call it delicious.

     Twelfth vitamin B

     Necessary, you see;

To preventing anemia pernicious

Weather in Barrow today turned warmer on the land and cooler over the ocean.  The sea ice reappeared a hundred yards from shore and covered the ocean out to the horizon.

For some reason there’s a lot of rheumatic disease on the North Slope.

Rheumatoid arthritis is not the same as wear and tear arthritis.  If the immune system is the army and police of the body, rheumatoid arthritis happens when the defenders mistake the civilians for the enemy.  People with rheumatoid arthritis do not feel well, they feel sick all the time, they have morning stiffness and if they sit too long they stiffen up, mostly in the small joints of the hands.  The disease waxes and wanes but until recently followed a relentless progressive course.

Methotrexate, a cancer chemotherapy agent, finds uses in small, weekly doses for those with RA.  Effective, to be certain, but it carries risks.  Hard on the liver, it interacts with a lot of drugs.  We usually prescribe methotrexate patients a milligram of folic acid a day to buffer some of the side effects, and stringently warn people not to use alcohol.

Over the counter vitamins by law can contain no more than 400 micrograms of folic acid a day for good reason.

Pernicious anemia was called pernicious because the patient got always died.  In the era of vitamin discovery, ground desiccated pig stomach (“hog maw”) was found to halt the progression of pernicious anemia.  Eventually, research showed that pernicious anemia resulted from a lack of vitamin B12, which only comes from animals.

Vitamin B12 works in concert with folic acid in several critical steps of blood manufacture and nerve repair.  Adequate doses of folic acid can mask a deficiency of vitamin B12 in the blood while the nervous system deteriorates irreversibly.

I‘ve seen a few cases of advanced B12 deficiency and they weren’t pretty.  Once B12 injections were started the progression stopped but every single one was left with permanent neurologic damage, some looking like multiple sclerosis and some looking like Alzheimer’s.

So when a patient comes to me already on folic acid for whatever reason (such as methotrexate therapy for rheumatoid arthritis, or replacement therapy for folic acid deficiency) I have an excuse to check the vitamin B12 level.  And few things give me as much pleasure as diagnosing B12 deficiency; I can save the patient’s life for less than two cents a day.

This morning I sat down to talk with a rheumatoid arthritis patient (who gave me permission to write this) about not only vitamin B12 deficiency but vitamin D deficiency as well.  

The first symptom of low vitamin B12 is a lack of energy, which can look for all the world like depression, as can hypothyroidism, autoimmune diseases, hepatitis C, vitamin D deficiency, electrolyte imbalance, drug side effects, testosterone deficiency and anemia.  Later on comes numbness, tingling, loss of coordination, and memory loss.

The sea ice broke up, the eczema responded to propranolol, the young respect the elders. And don’t use possessives when you talk about whales.

June 25, 2010

I’m learning the Inuit tongue,

Enjoying respect from the young.

     It’s a terrible loss

     To get hurt blanket tossed

These are wonderful folk I’m among

I have permission to give the following information.

A teenaged patient with eczema, severe to the point of disability, came in a couple of weeks ago.  For reasons clear to me only at the time I did a thyroid test and his TSH was slightly low, indicating an overactive thyroid (the current primary thyroid test, the TSH or thyroid stimulating hormone, measures the brain’s demand for thyroid hormone; low levels indicate excessive circulating thyroid hormone).   A week or so ago I prescribed propranolol.  The eczema is markedly better today; the patient looks happier and is sleeping better. 

Next time I have a patient with poorly controlled eczema, I hope I remember the patient who had been to multiple dermatologists for years and got better with propranolol.

The patient was happy, the relative was happy; I could see things had turned out well, and I came away with job satisfaction. 

The young people treat me with great respect.  I commented on that to a knot of early twenty somethings.  They smiled at me with grandchild-like love and talked about how reverence for elders is part of the culture.

I got to talk to two people with critically low vitamin D levels, in the single digits, today.  Both have diffuse bone pain.  I explained how calcium doesn’t get absorbed or used properly without vitamin D, and in compensation the calcium in the bones gets mobilized.  Which keeps the circulating calcium up at the expense of skeletal strength.

Alas, one of the two uses narcotics recreationally; I hold confidence that I’ll make the bones better but I harbor no illusions that the narcotics seeking behavior will stop.  I hope I’m wrong.

The sea ice broke up in the early hours today.  This morning, working on the elliptical, I watched white ice flows on blue water floating slowly south, pushed by the winds. 

We’ve seen the first Nalukataaq injuries.  I’m a person with enough sense to say that blanket tossing looks like fun for the young but not for me.  Not everyone agrees with me.

My Inupiak language acquisition program is progressing.  I’m in the stage of echolalia, where I can repeat short sentences but I don’t know what they mean.  I was able to say “Good morning.  How are you?  I’m fine.  My name is Dr. Gordon.”  But my head is not in the language and the language has not taken root in my head.  I am, however, working on it.

Seeking to get a better handle on the grammar, I asked one of my informants how possessives are handled.  I got a blank stare.  I have a limited number of nouns in my vocabulary, so I started with whale, agvik.  “How would you say my whale?” I asked.  I got another blank stare.  Finally the informant said, “You wouldn’t say that.  You never say my whale or your whale or even our whale.  You just say whale, ahagvik.

Wernicke without the Korsakoff, don’t hold the thiamine.

June 18, 2010

I tell you in Barrow there’s a need

For independents of the medical breed                         

     And, what is more,

     They need a drug store.

Do I have to appeal to greed?

Labs this morning included a folic acid deficiency, another hyperthyroid, and a hyperparathyroid.

Folic acid deficiency should be as rare as snowy owls eating black-footed ferrets but it isn’t.  Left untreated, folic acid deficiency is fatal.  Treatment runs a few cents a day for a simple pill.  I find the diagnosis and treatment of this problem very gratifying; not only do I get to save the patient’s life for little money but I get to make them feel better.

A call from Anchorage led to a discussion of Wernicke’s encephalopathy.  Neurologic problems happen from thiamine deficiency and carbohydrate excess.  As all food stuffs containing flour have thiamine supplementation, the worst carbohydrate with no thiamine (one of the B vitamins) is distilled alcohol.  A person has to drink very hard and keep a strictly rotten diet to get Wernicke’s.  Thiamine deficiency more often gives rise to Korsakoff’s psychosis, where a person loses short-term memory.  Med school vitamin discussions featured Wernicke-Korsakoff syndrome, and in med school I learned but I scoffed.  I shouldn’t have.

Vitamin D deficiency gives rise to hyperparathyroidism which in turn gives rise to osteoporosis, and the vitamin D level on the patient with the abnormal parathyroid is pending.  I will be very surprised it the vitamin D level is normal.

For reasons of confidentiality I cannot go into details about the people the abnormal lab results are associated with, but they are living, feeling human beings who suffer and who hurt; they live in families; they make good decisions and bad; each one has stories to tell, full of drama and irony. Each wants to be done with illness and move on with their lives.

I still had paperwork to fill out for my hospital appointment, the deadline loomed, and the completion took up much of the time freed by clinic no shows. 

The Indian Health Service started the hospital in Barrow.  The Arctic Slope Native Association took over the operation in 1995, and in the process started delivering health care to the non-Natives.  I suspect that out-of-pocket expenses for an Urgent Care visit are like prices for everything in Barrow, that is, very expensive.  The non-Natives come for work physicals, workman’s compensation, coughs, colds, and the occasional head scratching mystery.  Sometimes they require services that are not available in the entire North Slope, and arranging follow-up becomes very difficult

Barrow would also be a good place for a doc to open up shop and serve the non-Native population, almost all of whom have very good insurance.  Such a doctor would do well here from first day.

It won’t be me.  I’m having too much of a good time being an employee, not being an owner, working at a reasonable pace.

A retail pharmacy would also do well here.

“I hurt my neck pulling in my gramma’s whale.”

June 16, 2010

Here is a heck of a deal

The oil that comes from a seal

     Has vitamin D

     And Omega three

But lacks universal appeal

A patient who said, “I hurt my neck pulling in my gramma’s whale” gave me permission to quote.

These are not words you will hear in Sioux City.

The more you do something the more likely you are to get injured doing it.  In turn-of-the-century Sioux City and current Arthur County, Nebraska, for example, horses regularly injured and killed people.

When I did industrial medicine for the packing plants in Iowa I saw overuse and animal related injuries.   A combination of carpal tunnel syndrome, tennis elbow, and biceps tendonitis comprised the syndrome we called “packer’s shoulder.” 

A whale is a very big thing.  It stands to reason that if you live in a place where whales mean the difference between starvation and plenty, people will get whale related injuries.

I don’t know that the following story is true; I suspect it is as I’ve heard the same details from multiple sources.  A group of people were pulling a whale onto the ice using a block and tackle.  The strap on the tail broke and the block and tackle rocketed backwards, killing two, including a doctor’s wife who was decapitated.

I am surprised I’ve seen no cuts from the very sharp tools used on whales. 

A great many people suffer from constipation because they eat so much muktuk (raw whale blubber attached to whale skin). 

They also suffer overuse injuries from cutting up the whale, including tendonitis of the biceps and the brachioradialis (the tendon in your forearm a palm’s breadth up from your thumb).  If I see enough cases, I might publish a paper and call it “whaler’s arm.”

I am surprised to have seen so little frostbite or its sequelae.

I opened my day with seven abnormal and two normal vitamin D levels.  I went to the pharmacist to work out a vitamin D replacement schedule.  I will start the patients on vitamin D replacement at standard doses but I’ll miss the follow up in 8 weeks. 

Seal oil is very high in vitamin D, and the only patients who have come up with normal vitamin D levels have been high consumers of seal oil.  But almost everyone here eats whale blubber, so I suspect it has little vitamin D.

Playing saxophone and singing in a Mexican restaurant in Barrow, Alaska

June 12, 2010

The guitarist made a hit with St. James,

The poster showed off my name,

    I felt like a king

    When they let me sing

But sometimes my playing was lame.

I went for a walk this morning in thrilling clear air instead of using the gym equipment.  I saw pressure ridges building in the weakening sea ice.  I found patches of intact tundra.  I saw my first lemming.

At morning conference we discussed the value or lack thereof associated with therapeutic modalities like trigger point injection.  Which brought us to a discussion of acupuncture.

I am the only doctor who holds acupuncture privileges at St. Luke’s in Sioux City, and only for the treatment of pregnant women who vomit so much they have to be hospitalized (hyperemesis gravidarum).   A spirited discussion followed.  We talked about the tribal doctors, who come to Barrow on a regular basis. 

I would like to meet them.  When I worked with the Navajo, from time to time my patients would complain of hemidynia: pain on one side of the body.  I knew that the medicine man could help the patient and I couldn’t.  We had a good working relationship. 

This morning I reviewed labs and found two cases of vitamin D deficiency, a borderline vitamin B12 level, a positive hepatitis C, positive rheumatoid factor, and a hyperthyroid.  In fairness, the rheumatoid factor turned out to be falsely positive, and the hepatitis C was already under treatment.

Most of the morning appointment patients didn’t show, and I had lots of time to do followup planning on the patients with abnormal labs.

In another setting I would have scribbled orders on a sticky note, slapped it on the chart, and handed it to the nurse, who would have Gotten It Done.  I don’t mind doing the work for myself here because I’m am not over worked.

Over the lunch hour I practiced my saxophone and didn’t nap.

On three occasions this afternoon I drew on my own personal medical experience to put patients at ease. 

The fact that I had a misdiagnosed chronic disease for thirteen years gives me credibility with patients suffering from a wide range of diagnoses.  “Here is how I learned to live with the pain…” opens a lot of productive discussions.  Of course I deliver impassioned sermons about nicotine, caffeine, and alcohol.

I finished walk-in clinic late and changed clothes, grabbed my sax, music stand, and music, and drove to Pepe’s North of the Border with Theresa, the wife of Mac, the physician-trumpeter, and two children belonging to the Clinical Director.

We used a vehicle belonging to the Arctic Slope Native Association (ASNA), the corporation that took over the hospital from the Indian Health Service in 1995, and indirectly employs me.  They are a very good outfit to work for.

Mac and the guitarist were already at the Mexican restaurant.  We opened at seven. 

The three of us sat at one end of the room.  We tried to get the crowd to bob their heads in time to the music, not overwhelm them.  For the most part we succeeded.

The crowd never exceeded twenty.  I only had two numbers ready for performance; Mac got me a pair of maracas, and the other people let me sing.

Forty years ago I couldn’t sing; I had the timing right but I hit the wrong pitch and I could hear it.  Ten years ago I could sing, but badly. In the last five years I’ve been able to sing, and in the last two I’ve sung well from time to time. Tonight my singing was better than my playing; I’m still having trouble with the cognitive dissonance inherent in playing a B blat instrument and reading from music written in C. 

The guitarist supplied with hit of the night singing St. James Infirmary, with me on back-up vocals.  We drew applause.

Afterwards Mac and I dropped the guitarist at his home, a block from the restaurant, and we detoured by the roller rink on the way back to the hospital.

 As of this writing, the sky has clouded over.

I’m on call tomorrow.  I don’t think I’ll practice my saxophone.