Why New York State Needs to Ammend the Concussion Management and Awareness Act

In September 2011, New York Governor Andrew Cuomo signed into law the Concussion Management and Awareness Act (sponsored by Senator Hannon and Assemblywoman Nolan), mandating that students can only return to play following a concussion after they are symptom-free for 24 hours and cleared by a physician. The intention of the law was to improve patient safety. However, the exclusion of one the most qualified types of health care providers (clinical neuropsychologists) from performing such evaluations can lead to patient harm by returning students too early (resulting in further neurological harm) or keeping them out of sports much longer than necessary (resulting in psychological harm). 

Neuropsychologists specialize in objectively assessing the relationship between brain functioning, thinking, emotions, and behavior – all of which can be affected in the early phase of concussion recovery. This is done through a series of specialized tests, records review, interview, behavioral observations, and application of statistical knowledge. Neuropsychologists also have much more time to spend with their patients than physicians due to the nature of the evaluation.

Neuropsycholgists have been instrumental in developing published return to play safety protocols and have routinely made return to play decisions prior to the passage of this legislation. Neuropsychologists developed the most popular computerized cognitive assessment programs that are used to make return to play decisions, have played a leading role in researching concussion for the past 25 years, and have published textbooks on the topic. A neuropsychologist from New York (Dr. Thomas Kay) was the senior contributor of the American Congress of Rehabilitation Medicine’s operational definition of concussion. Nearly all major college and professional sports organizations include neuropsychologists in their concussion management program and most states that have passed similar legislation allow neuropsychologists make return to play decisions.

Concerns were expressed to the sponsors of this bill and the Governor’s office about the exclusion of neuropsychologists before its passage. Neuropsychologists were assured that neuropsychologists would still be able to play a role in these assessments that would be used by physicians. However, some school districts are only allowing return to play decision to be made from a specific list of physicians (e.g., pulmonologists, orthopedists, pediatricians) who do the entire assessment without any input from a neuropsychologist. If the child’s own pediatrician is not on the official list of providers, he/she may not be allowed to provide clearance to return to play.

Due to this potential safety issue and the new restriction upon a psychologist’s scope of practice, we urge parents and concerned citizens to contact Senator Hannon, Assemblywoman Nolan, Governor Cuomo, and their local representatives to tell them that you strongly support allowing psychologists to be included in a bill that allows them to make return to play decisions following concussion. as an update to this article, please see How New York Fumbled the Ball on Concussion Management.

New MedFriendly Redesign Sneak Peak Is Up

As previously noted, MedFriendly is currently undergoing a major site redesign. The difference is like night and day. The site will have a much more professional look to it, pages will load faster, will be indexed even higher in search engine results, and the overall user experience will be greatly enhanced. For a sneak preview, you can click on the new Advertising page. If you click the white text links on the top left of the page, you will be see some of the other new pages as well, all with the same new design (except for the Blog and Message Board of course).

All newly created pages will have this new design. The main MedFriendly home page is still being redesigned and will hopefully be up within a week. Please feel free to let me know how you like the new look if you have not done so already.

Guest Blog Entry: A Comparison Of The US And UK Head And Brain Injury Compensation Law

The following provides an overview of the US and UK legal systems regarding head and brain injuries compensation, when said injuries are sustained through road traffic accidents. The aim is to provide an interesting comparison, as well as an insight into what you can expect to encounter when seeking compensation.

Both legal systems work on a fault based principle. In the US there are federal laws to abide by, and state laws, which differ from state to state. This is where cases can become more complicated, as motor insurance is not compulsory in all states. For this reason some claimants will have a harder time acquiring justice and compensation. Also dependent on state laws, is the recovery of level of damages. Awards, which are compensation for pain, suffering and loss of amenity, are determined by a jury, in contrast to the UK, where awards are made by a judge. In the US awards are distributed using a top down system. They can be distributed as a lump sum or structured settlement, thereby creating an annual income. In the UK a bottom up system is in place, meaning the annual income is established by determining the claimants financial need based on injuries, past and present medical costs, and rehabilitation costs, and then meeting this need. 

The countries’ systems also vary when handling legal costs. In America, the legal costs are commonly dealt with under a contingency fee. There are no initial costs for the claimant and their family, as the attorney can take a percentage of the compensation, once the case is concluded. This percentage is agreed upon by attorney and claimant at the beginning of the case, and is dependent on the risk involved in said case. 

In comparison the general idea behind the UK’s compensation system of all personal injuries, including head injury, and following traumatic brain injury, is to provide the claimant with enough compensation so that they are in the same position they were prior to the road traffic accident. To note, when referring to the UK law in this article, what is meant is the law in England and Wales, since Scotland and Northern Ireland have different compensation laws. The process works as follows: Expert evidence is acquired from experts within medical and non- medical fields. The award is again based on pain, suffering and loss of amenity, by assessed through referencing guidelines, previous, similar cases, which are concluded, and the personal circumstances of the claimant. When discussing financial losses, these are defined as past and future loss of earnings, medical expenses, treatment, equipment need, and accommodation. For a brain injured claimant, the largest section of an award is the cost of their future care, be it at home or in a different setting, i.e. a rehabilitation unit. Rehabilitation has a strong focus within the UK’s compensation process, and is based on encouraging both claimant and defendant to work together and asses the injured individual’s rehabilitation needs. 

Another difference to some states of US, are laws on motor insurance. In the UK motor insurance is compulsory, and there is also the Motor Insurers Bureau, which compensates victims of uninsured or untraced drivers. 

As in the US awards are given as sums of money, or periodical payments providing guaranteed for life annual payments based on the individual’s needs and covering both care and case management costs. In general, legal costs are fully recoverable from the defendant, and a brain injured individual will receive 100% of their compensation, if their claim is successful. 

Neither of the presented legal systems are perfect, and neither are wrong. We can learn from each other’s laws. It is also good to be aware of different countries’ laws, in case of sustaining head and brain injuries through a road traffic accident, when abroad. Here, it is equally vital to find an attorney with knowhow of jurisdictional and applicable law rules. You will require specialist advice to ascertain if you can bring your claim in the country of your choice and if there is a choice of jurisdiction which is the most appropriate venue for your claim. It may be that attorneys from both companies are required to work together to ensure the best outcome for you.

When seeking compensation for head and brain injury in either country, it is important to find an attorney with experience and expertise within head and brain injury cases. It’s best to research attorneys and to meet the one you are considering, to be sure you both get on with each other and can imagine working together as a team.   

Today's guest blog entry was written by Pannone.

Where the Republican Candidates Stand on Health Care

As I was watching the Republican Presidential Debate last night, I thought I would take a closer look at the candidate's websites to find more details about where they stood on healthcare. No matter what your view is on the Patient Protection Affordable Care Act is (also known as Obamacare), the United States Supreme Court will be hearing Constitutional challenges to it, probably in March 2012. Thus, it is going to be a very important issue throughout the election. Of the six candidates, what I found interesting is that two of them have no information about what they would do to fix the healthcare system. A person by person breakdown is listed below, along with links to the sections of their websites discussing healthcare or their stands on various issues. The list is provided in alphabetical order.

1. NEWT GINGRICH: Gingrich lists 13 main ways he would improve healthcare, which include various specifics. This includes use of tax credits, purchase of insurance across state lines (to improve competition), expanding choices in Medicare, customizing state Medicaid systems, establishing a high risk people to cover the sickest uninsured citizens, preventing insurers from cancelling insurance on people who are very sick or giving them discriminatory rates, extending health savings accounts, rewarding the best healthcare provided at the lowest cost, taking steps to reduce healthcare fraud (e.g., electronic medical records), medical tort reform, reforming the FDA,  helping people find information on price and quality of healthcare, and investing in medical research.

2. MITT ROMNEY: Romney lists six main ways he would improve healthcare, which alos contain various specifics. He states that would begin his Presidency by granting an executive order to states to opt out of Obamacare, ask Congress to repeal Obamacare, and emphasizing reforms at the state level. The second area Romney cites involves focusing on the states by block granting funds for Medicaid patients and the uninsured. He also promotes a tax deduction to allow people to purchase their own health insurance. His fourth main idea is reforming federal regulations such as allowing people to purchase insurance across state lines. His fifth idea is medical tort reform. Lastly, he promotes the use of health savings accounts.

3. RON PAUL: He pledges to repeal Obamacare (although you need Congressional support for that), allow purchase of insurance across sate lines, provide tax credits and deductions for all medical expenses, exempt terminally ill patients from the employee portion of the payroll tax, provide payroll deductions for close family members of terminally ill patients, medical tort reform, preventing Medicare & Medicaid funds for being used for other purposes, allow all Americans to open health savings accounts, promoting alternative medicines and supplements, and preventing a national database of personal health information.

4. MICHELE BACHMANN: She states that she will repeal Obamacare, stabilizing Medicare for future generations,promoting medical innovation and personal choice, promoting competition in the healthcare market, and empowering health care providers to make decisions about the shape and form of your health insurance.

5. JOHN HUNTSMAN: While his website contains sections on jobs and the economy, national security, foreign policy, energy security, and financial regulatory reform, there is no section on healthcare.

6. RICK SANTORUM: While his website contains information on defending the taxpayer, American exceptionalism, faith and family, Iran, and other topics, there is no section on healthcare.

Interestingly, the two candidates with no clear distinct section on healthcare on their websites are generally running lowest in the polls.

All Brain Injuries are Not the Same: Part 2

Today’s blog entry is part 2 of yesterday’s blog entry about the reasons why it is important to distinguish mild traumatic brain injuries from moderate to severe traumatic brain injury as opposed to lumping them all together under the term “brain injury”. Further explanations as to how this distinction is important includes:

4. NEUROIMAGING: In moderate to severe TBI, the results of neuroimaging are critical to deciding how to manage the patient. For example, if a bleed is large enough, this might require neurosurgery to remove pressure on the brain. This sometimes requires repeat brain scans in the acute injury phase to monitor the size and effects of an intracranial lesion (e.g., a brain bleed). In MTBI cases, initial neuroimaging results in the ER do not show abnormalities between 90 to 95% of the cases. Thus, after an initial negative brain CT scan, clinical management of the MTBI patient is often based on subjective symptoms (e.g., headache) rather than objective findings.

5. COURSE: In moderate to severe TBI, the recovery course is well-defined and empirical, with the most drastic improvement occurring in the first six months, additional recovery over the next six months, and slower recovery up to 18 to 24 months. In mild TBI, the course of recovery is clear for the vast majority of people which would suggest that most recover within a week to a few months. However, the course of recovery for those who experience persisting symptoms (more than three months) is less clearly understood.

6. OUTCOME: As noted above, outcome is strongly related to acute injury characteristics in moderate to severe TBI cases and it is generally an exception when psychological factors confound outcome (although this certainly can occur). Conversely, in mild traumatic brain injury, outcome is poorly related to acute injury characteristics. Rather, non-injury related factors tend to be the most predictive of outcome. Examples of non-injury factors include litigation/compensation-seeking, psychological distress, pre-injury psychiatric history, post-injury stressors, substance abuse, and various other psychosocial issues.

7. DISABILIY: In moderate to severe TBI, disability (a form of outcome) is more clearly attributed to injury severity, the functional neuroanatomy of the injury, and resulting impairments. In mild TBI, there is a less clear association between the clinical presentation of the patient and the degree to which neurological and psychological factors play a role.

These examples show that one cannot speak of traumatic brain injury as if it has the same meaning across the severity spectrum. The media and health care providers are strongly encouraged to clearly distinguish between mild and moderate to severe brain injuries when discussing this topic with patients and the public.

All Brain Injuries are Not the Same: Part 1

One of the most popular myths in the media and among some health care providers is that traumatic brain injury (TB) can be discussed as a unitary concept. In other words, the topic is discussed as if it is not necessary to make a distinction between a mild and moderate to severe TBI. In fact, it is quite necessary to make the distinction rather than broadly discussing the effects of “brain injury.”

Unfortunately, what often happens is that findings from patients with moderate to severe TBIs are misapplied to those with injuries on the mild end of the spectrum. As Dr. Michael McCrea (2008) writes in his evidence based text, moderate to severe TBI is a completely different animal than mild TBI (also known as concussion). There are many examples, which are nicely summarized in McCrae’s text and the interested reader should read that book for specific references supporting the statements below. Some of these examples are presented and expanded upon below to help better inform the public.

1. USEFULNESS OF SEVERITY GRADING TOOLS: In moderate to severe TBI, there are measures available that are useful for grading the severity of the injury whereas the scales on the mild end of the spectrum are not as helpful. The most commonly used severity index is the score on the Glasgow Coma Scale (Teasdale & Jennett, 1974) which assesses level of consciousness. The scale ranges from 3 to 15 points and provides a way to rate patients on their eye movements, motor responses, and verbal responses. The TBI classification scheme based on the GCS is as follows: 13-15 (mild), 9-12 (moderate), and 3-8 (severe). While a significant injury and/or alteration in consciousness is required to obtain a GCS score between 3 and 12, the same cannot be said for the mild end of the TBI severity range. For example, consider a person who merely bumps his head into a wall with a minimal degree of force that was not significant enough to cause a brain injury. Assume, however, that the person develops a headache and is concerned that he has a brain injury, causing him/her to go to the ER. When the person goes to the ER, he/she is physically examined and a GCS score of 15 is assigned because there were no abnormalities with eye movements, motor responses, or verbal responses. According to the criteria above, a GCS score of 15 is equated with a mild TBI. Clearly, however, this example shows a GCS score of 15 does not always equate to brain injury.

2. ACUTE INJURY CHARACTERISTICS: In moderate to severe TBIs, the acute injury characteristics are the strongest predictors of outcome. In mild TBIs, there is only a limited correlation between acute injury characteristics and outcome. For example, in mild TBI, a brief and transient loss of consciousness is not strongly predictive of outcome. Conversely, loss of consciousness in a severe TBI patient, which could last for weeks and beyond, is strongly correlated with outcome. One of the problems is that acute injury characteristics are not as clearly documented in MTBI cases because of a lack of witnesses and the transient nature of the event. For example, a mild TBI patient may lose consciousness for a few minutes but if no one was present to witness this, it cannot be confirmed. Conversely, in a moderate to severe TBI case, LOC usually lasts long enough such that paramedics or some other observer would be able to confirm its presence.

3. CRITERIA FOR DIAGNOSIS: The criteria for diagnosing moderate to severe TBI tends to be more consistent throughout the literature compared to mild TBI. The criteria used to diagnose MTBI are largely based on self-reported subjective symptoms (e.g., altered mental status) without collaborating and/or objective data (e.g., witnesses, neuroimaging findings). In moderate to severe TBI, objective data are often sufficient enough (e.g., diffuse bleeds throughout the brain) such that self-report is not required to make the diagnosis.

Come back tomorrow for part 2, in which more distinctions will be provided.

 REFERENCES

McCrea, M. (2008). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.

Teasdale, G, Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2:81–84.

Why Physicians Need to Pay Attention to Malingering And Exaggeration

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs (APA,1994).

The word “malingering” comes from the French word “malinger” meaning “poor or weakly” as these are the characteristics feigned or exaggerated by the malingerer. Malingering has been documented as far back as in the Bible when David feigned insanity to escape a king he was afraid of. There have many books written about malingering and thousands of research articles written about it.

Malingering and/or exaggeration for external gain are both common in society. For example, last week, 18 people were arrested in New York State for workers compensation fraud. At a minimum, when one adds up how much money the state of New York paid out on fraudulent claims in these cases it comes to at least $243,000. To have pulled this off, it required physicians and other health care professionals to have signed off disability claims forms. While malingering can manifest by verbally feigning or grossly exaggerating symptoms, some people go through much greater lengths to malinger. For example, last week a California psychologist was accused of faking her own rape by splitting her own lip with a pin, scraping her knuckles with sandpaper, having her friend punch her in the face, and wetting her pants to give the appearance she had been knocked unconscious. The motive? To convince her husband to move from the neighborhood.

On 12/11/12, a Virginian woman was charged with fraudulently claiming that she had cancer to raise money from sympathetic supporters for personal reasons. She’s not the first to have done so. Earlier this year, a man was arrested for fraudulently obtaining almost a million dollars in sympathy donations by claiming he had cancer.  

Physicians and other health care professionals should be very concerned about exaggeration and malingering because they are enabling the process if they are not taking reasonable steps to detect it and address it. Many health care providers do not address this topic in their exams or clinical notes for several reasons, included but not limited to, a) not wanting to deal with the “hassle” of identifying the problem, such as confronting someone (which can be uncomfortable) and/or dealing with complaints, b) extreme patient advocacy, c) not wanting to believe that some patients distort their presentations for external reasons due to an overly trusting worldview, and d) concerns that identification of this problem will harm the patient in some way (e.g., loss of benefits).

While false positive identification of malingering and exaggeration is a legitimate concern (of which there are many ways to address this in the scientific literature), not identifying it can harm other patients and society in two main ways. First, malingering and exaggerated presentations rise insurance costs for all citizens because the insurance company has to spent thousands of dollars on services/treatments that need not be provided or at least not to the extent that they were provided. Most importantly, however, patients with more genuine needs have delayed access to health care services because appointments are taken by people who are trying to game the system and/or who do actually need that particular service.

While a public forum is clearly not the appropriate place to discuss malingering and exaggeration detection strategies, healthcare providers need to go to greater lengths to consider and assess response bias in their evaluations or at least refer to someone who will. There are many texts, research articles, conference workshops, and invited speakers that can be used as sources to provide healthcare providers with more information on the topic. A recent article written by myself and some colleagues discusses how to provide feedback about malingering and exaggeration to the patient. An upcoming edited book entitled Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering (Publisher: Springer) by myself and Dr. Shane Bush will address this topic and many others (including techniques that general healthcare providers can use).

Ultimately, you cannot effectively treat patients who do not want to get better and who do not actually have the problem you believe you are treating (or have it but to a much lower extent than they are claiming). This does not mean every patient is treated like a malingerer, but rather, that objective data (which can be obtained via a neuropsychological evaluation) combined with clinical experience and research knowledge should be used to guide clinical decision making as opposed to purely relying on subjective reporting, subjective impressions, and a desire to help. All of this can be done in a respectful, caring, and patient centered way.

Also see: Why Sports Leagues Need to Pay Attention to Malingering.

Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.

MedFriendly in 2012: The Redesign is Coming

When I first created MedFriendly in 2001, I had no knowledge whatsoever as to how to make a website. I picked up some books to learn how to write in HTML (hypertext markup language) and also read some online tutorials. HTML is the computer language behind the scenes that tells your browser (e.g, Internet Explorer, Firefox, Chrome) how a webpage should look. Back is 2001, it was acceptable to create websites this way.


Things were much simpler back then. But, as always happens, technology improved and more advanced website design features began getting implemented into websites. These design features became impossible to render without more advanced computer knowledge. Lacking such knowledge (my only computer class was in the 3rd grade on massive cathode ray tube monitors) I kept finding creative ways around this problem and managed to keep the site looking fresher as the years went by.

Over the past few years, I integrated a centralized database system which serves all of the advertisements you see on MedFriendly (except the blog). This way, if an advertiser changed their ad code throughout the site, I did not need to go to every page and fix it. All I had to do was change the ad code in the database. To use a database, I needed to change all of MedFriendly page extensions (except the home page) from .html to .php5. It was a great deal of work and when it was finally done, although I solved one problem, I had inadvertently created another. Pages loaded slower and Google did not rank .php5 pages as highly as .html pages. This means less visitors to the site.

Converting all of the pages back to .html files the way I had them was unthinkable. Not without a new approach. Fortunately, technology has advanced to the degree that there are many good options out there today and I am now working with what is known as a content management system. This will allow me to create the highest quality web pages with a very professional look and will allow me to easily control all aspects of the site from a single master location. Pages will load much faster, the site will be more secure, and I will be able to add so many new features to the site that the sky is the limit. I have begun working on this project today and will update readers here on the progress. Since this project is so massive, there may be days where a blog entry can’t get done, but it is all for the greater good. MedFriendly simply has to modernize to stay relevant and I am dedicated to doing that. I appreciate your readership and support and would greatly appreciate hearing ways you believe the site can be better such as new features you would like to see. Stay tuned.

Suicide by Piranha

According to U.S statistics, the most common cause of suicide is use of firearms (55%). Second is hanging or suffocation (20.2%). Third is poisoning (e.g., drug overdose, cardon monoxide poisoning) (17%). Fourth is falls (e.g., jumping off a building) (2.1%). Fifth is cutting/piercing (e.g., wrist slicing) (1.5%). Sixth is drowning (1.1%). Seventh is fire ( 0.5%). 

RECOMMENDED BOOK: When Darkness Comes: Saying "No" to Suicide

What’s not on the list? Jumping into a lake of piranhas. That’s what a teenage fisherman in Bolivia chose to do when he jumped off a canoe in an intoxicated state. The piranha converged on him and he bled to death by suffering dozens of bites from the razor sharp teeth on his throat and face. All that was needed was one bite sized chunk to be removed from his jugular vein and it would spell the end. The teenager was drunk at the time so one can question whether he was thinking clearly about what he was doing but the local police chief is on record saying that this person knew the area very well and knew that there were scores of piranha in the lake that time for year. 

Piranha are ferocious fish. They are rumored to be able to strip the flesh off of a large animal in minutes when attacking in packs.One of the most interesting things I learned about piranha’s was from Jeremy Wade on one of my favorite shows, River Monsters. On one of the shows, he jumped in a lake of piranhas but remained very still. No bites. As soon as he threw a pole in the water (once safely in a boat) and began thrashing the line, near-instant bites. Piranhas, it seems, are attracted to the thrashing of an animals because it signals helplessness. Just remember that if anyone ever throws you in a lake of piranhas.

Don't Let the Bedbugs Bite!

Don’t let the bedbugs bite. What used to be a funny phrase uttered to children before tucking them into bed has now become a serious concern for people sleeping in hotels, college dorms, hospitals, shelters, and in their own homes. This pandemic has made many consider staying home from a vacation or enrolling in online classes for college. But what are bedbugs anyway, what do the bites look like, and what can you do to get rid of them? Below is a pictoral guide that gives you some of these answers.

First, here is a picture of a bedbug (also known as Cimex lectularius) under the microscope. The purple looking structure is a needle-sharp body part known as a proboscis, which is inserteded into the host’s skin (human or animal) and allows it to feed on blood for about three to five minute. The bedbug injects saliva into the wound that contains anesthetic (pain reliever) to prevent the host from awakening and anticoagulant to keep the blood from clotting.

Here is what a bedbug looks like when magnified without distorting the color although this picture is also magnified:

Bedbugs are actually very small (less than or equal to a half a centimeter) but you can see them without a microscope if you are a keen observer. As you can see from the picture they are flat-shaped and do not have wings. They can be brown or whitish but after drinking blood turn a rusty red color as a result, like this:

Bedbugs are attracted to carbon dioxide and body heat so they like to be where people are. They are called bedbugs because they like to hide in mattresses and bedding. They hide in small crevices and can be in luggage, boxes, trash, furniture, and clothes. Humans are dinner sources for them and their favorite time to feed is just before the sun rises. When finished with their meal, they swell up like a tick. Unlike ticks, they then fall off the host, crawl into their hiding place, and digest their meal. They sometimes leave blood stains along the seams of mattresses but can also leave dark droppings behind as well.

The first sign that a bedbug has bitten you are red itchy bites that look like this usually on the arms or shoulders, sometimes in straight rows:

The bites don’t usually need to be treated but they can get infected, especially when scratched. In this case, or when the skin reaction is more severe, seeing your doctor can result in treatment. This can be treated with antiseptic lotions and/or creams. Creams with corticosteroids may be used to decrease inflammation. Creams with antihistamines may be used to decrease the itching. These creams can also be used if there seems to be an allergic reaction or if the skin reactions get bigger like this:

Although most common in developing countries, they have been present in North America more due to increased international travel. They can live for 10 months and can go weeks without food. The good news is that bedbugs do not appear to carry or spread human disease.

How to get rid of them? Get rid of mattresses and box springs infested with bedbugs. You can also cover the bed with a plastic mattress bag to trap the bugs. Infested clothes and bedding should be washed in hot water and dried on high heat. Any furniture of cracks (e.g., in wood floors or doors) should be cleaned and vacuumed as should suitcases. Calling an exterminator is another option. If you use your own insecticide (e.g., in cracks of floors or bedframes) this should not be applied to areas that result in direct skin contact.

SHOCKING Psoriasis Pictures from 1899

There is nothing quite like going through old medical textbooks to see how the authors used to present medical conditions in pictures. These days, authors go to great lengths to protect confidentiality by not showing the patient’s face or by placing black bars over the patient’s eyes. In the late 1800s and early 1900s, patients were shown with various ailments, with the face and eyes for all to see. The pictures of the conditions also differed back then in being quite startling, whereas today’s medical texts are sometimes less dramatic in terms of the pictoral presentations.

MedFriendly will be featuring some entries from time to time highlighting what some classic medical texts showed about various medical conditions in the late 1800s to early 1900s. The first entry is about the skin condition, psoriasis. Psoriasis is a common condition that many people have which causes redness and irritation. It usually causes thick red skin with flaky silver-white patches. It is a lifelong condition that can go away for a long time but later return. It often occurs on the elbow but can occur anywhere. It can be a rather unsightly condition. What many people do not know is that it can actually be disfiguring.

Below are some pictures of psoriasis from an 1899 text called Atlas of diseases of the skin by Dr. Franz Mracek. Here is a leg:

Foot

Leg

Arm

Back

Belly

Hand

What's Causing My Headache?!

Headache is one of the most common symptoms we all experience. Sometimes, the cause is serious and other times it is not. Below is a list of indicators that may suggest the particular causes of a headache. Please keep in mind that these are possibilities and that you should consult your doctor for more information. You should also consult your doctor if your symptoms do not match the patterns described on the following list:

FEVER: Headache with a temperature over 100 degrees.

EPIDURAL HEMORRHAGE: An epidural hemorrhage is bleeding outside of the outermost layer that covers the brain. Symptoms include a headache with a head injury in the past few days, in addition to feeling unusually drowsy, and/or vomiting, or feeling nauseous (sick to one's stomach). No temperature over 100 degrees Fahrenheit (F). If this applies to you, it is an emergency, and you should get medical help immediately.

HEAD INJURY: Headache with a head injury within the past few days, without feeling unusually drowsy and/or vomiting, or feeling nauseous. No temperature over 100 degrees Fahrenheit (F). A continuous headache is common following a head injury.

RAISED PRESSURE IN THE EYE: Severe pain in and around one eye, blurry vision in that eye, and nausea or vomiting. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. If this applies to you, it is an emergency and you should get medical help immediately.

SUBARACHNOID HEMORRHAGE: A subarachnoid hemorrhage is bleeding between the first two layers that cover the brain. Symptoms are headache, nausea and vomiting, as well as two or more of the following symptoms: dislike of bright light, drowsiness or confusion, and pain when you touch your chin to your chest. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No severe pain in and around one eye. If this applies to you, it is an emergency and you should get medical help immediately.

INFLAMMATION OF ARTERIES IN THE HEAD: Nausea and vomiting as well as a sudden throbbing pain in the side or sides of the head. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No severe pain in and around one eye. No dislike of bright light, drowsiness or confusion, or pain when you touch your chin to your chest. If this applies to you, it is an emergency and you should get medical help immediately.

MIGRAINE HEADACHES (see section above on different types of headaches for description): Nausea as well as disturbed vision that occurs with vomiting, followed by pain on one side of the head. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No severe pain in and around one eye. No dislike of bright light, drowsiness or confusion, or pain when you touch your chin to your chest. No sudden throbbing pain in the side or sides of the head.

DRINKING TOO MUCH ALCOHOL: Experience of a similar headache while waking up the past several days or more out of the past week. The headache occurs only when drinking a lot of alcohol the night before. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting.

TENSION, BRAIN TUMOR, OR HIGH BLOOD PRESSURE: Experience of a similar headache while waking up the past several days or more out of the past week. The headaches do not occur only when drinking a lot of alcohol the night before. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. If the pain is in the back of the head, tension or high blood pressure is a more likely cause than a brain tumor. If nausea and vomiting is present and the headache reoccurs and is experienced while waking up, this indicates a brain tumor. If the group of symptoms mentioned in this paragraph applies to you, it is an emergency and you should get medical help immediately.

SINUSITIS: Sinusitis is inflammation of air-filled openings (known as facial sinuses) in the bones surrounding the nose. Symptoms are a current or recent stuffy nose and a dull pain and pain to the touch around the eyes and cheekbones that worsens when bending forward. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting. No similar headaches while waking up the past several days or more out of the past week.

COMMON COLD: Headache and a current or recent stuffy nose. No dull pain or pain to the touch around the eyes and cheekbones that worsens when bending forward. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting. No similar headaches while waking up the past several days or more out of the past week.

NERVOUSNESS, TENION HEADACHES: Headache and feeling tense or under stress and/or having poor sleep. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting. No similar headaches while waking up the past several days or more out of the past week. No current or recent stuffy nose.

STRAIN ON NECK MUSCLES: Headache that occur after reading or doing work that requires you to be close to something, such as sewing. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting. No similar headaches while waking up the past several days or more out of the past week. No feeling tense or under stress and/or having poor sleep.

COMMON CAUSES SUCH AS: Hunger, drinking more alcohol than usual, being in a stuff, noisy, smoky area, exposure to strong sunlight. Headache, with the common causes just mentioned, occurring in the 12 hours before the headaches began. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting. No similar headaches while waking up the past several days or more out of the past week. No feeling tense or under stress and/or having poor sleep. Headache does not occur after reading or doing work that requires you to be close to something, such as sewing.

MEDICATION SIDE EFFECT: Headache in addition to taking medication and/or taking birth-control pills. No temperature over 100 degrees Fahrenheit (F). No head injury within the past few days. No nausea or vomiting. No similar headaches while waking up the past several days or more out of the past week. No feeling tense or under stress and/or having poor sleep. Headache does not occur after reading or doing work that requires you to be close to something, such as sewing. The common causes mentioned in the last section have not occurred within 12 hours before the headache began. You should talk to your doctor if you think a medication side effect is causing your headache.

Dentist Threatens to Sue Patient for Negative Review

There are many websites where you can find reviews of doctors by patients. While some helpful information can be gained by perusing such sites, one has to be careful before drawing too many conclusions from the reviews. The reason is because it is human nature to take the time and energy to complain when upset as opposed to writing something positive when you are happy. Therefore, patients are more likely to post negative experiences on such websites, leaving a skewed set of results. Many doctors, particularly those in private practice, do not like these types of websites because one or more negative reviews can turn away business.

As a result, some doctors have resorted to having patients sign contracts to prevent them from publishing any commentary or writing anything disparaging about their experience with the doctor. One New York City dentist (Dr. Stacy Makhnevich) did just that recently and then threatened to sue a patient (Robert Lee) who wrote a negative review on a website about her. The patient stated that the dentist billed him $4766 after sending the necessary paperwork to the wrong insurance company and refusing to hand the forms over so he could submit them himself, instead referring him to a third party who charges 5% of the total bill for the service. For each day the negative review remained online line, $100 was allegedly charged to the patient from the dentist.

Guest Blog Entry: Medical Advancements Come Out of Current Wars

Today's guest blog entry was written by Nick Jameson.

Since the earliest days of human civilization, war has been a regular and repeated phenomenon that destroys lives and tears societies apart. In its earliest days, a war required the mobilization of every member of a given state, and its ultimate victory or defeat promised to forever alter the fabric of that civilization. Then, for several centuries during the Middle Ages, the Renaissance, and the Industrial Revolution, war reverted to a more small-scale affair among professional armies. Countries won, and lost, and gained territories, but life for the average person continued unchanged.

The past century has seen a return to total war – one that involves every member of society. World War I and World War II were momentous and bloody events that defined a generation for anyone living in an affected country. Together, the two wars killed millions upon millions of people and completely altered the course of modernity.

But the World Wars also ushered in tremendous advancements, many of which would not have occurred – or, at least, would not have occurred as quickly – without having war as a stimulus. On a technological level, advancements were made in nearly all aspects of military engagement: planes and naval ships were improved, the atomic bomb was developed, and communication lines were strengthened. Furthermore, on a medical level, the war ushered in the widespread use of penicillin, various immunizations, and gas masks in response to chemical attacks.

The medical advancements seen in World War II come as little surprise, considering that millions of injured and sick soldiers were being treated by some of the smartest doctors and scientists out there. Consequently, such advancements realized in the face of a major war can be seen as a silver lining amidst all the death and bloodshed. While companies such as Huntingdon Life Sciences are always pursuing the latest medical breakthroughs, it is during a time of war when the full resources of society and of the federal government get behind this endeavor.

So what, then, are the medical advancements coming out of our current wars in Iraq and Afghanistan? While neither engagement can be described as a total war, both conflicts have been among the costliest in history, and they have both made use of countless technological advancements. With Iraq coming to an end and Afghanistan winding down, it is a good time to start considering the medical improvements that these wars may leave as their legacies.

The two main medical advancements of our current wars come in the areas of mental health and prosthetic limbs. For years, veterans suffering from Post-traumatic Stress Disorder (PTSD) upon arriving home from combat were brushed aside, their problems not fully understood. These days, veterans with PTSD are usually diagnosed and provided treatment. But the recent wars in Iraq and Afghanistan brought that treatment to a new level: thanks to medical advancements in the realm of diagnosis and drug treatments, the U.S. military is better equipped to identify those veterans with PTSD and work to help them readjust to society.

Advancements in prosthetic limbs have been equally beneficial to a different type of injured soldier returning home. Although casualty rates in Iraq and Afghanistan have been far surpassed by other American wars, the injury rate is high and veterans are arriving home with limbs that have been amputated or blown off by a bomb. In past wars, these veterans would have had little recourse but to learn how to live without that limb. This is no longer the case. As a result of advancements in biomedical engineering, veterans can be retrofitted with prosthetics that act – and even look – just like a natural limb.

These advancements will continue to benefit civilian society long after the wars are over and the soldiers have arrived home. While the life lost during a military engagement is almost always senseless and unnecessary, we can take heart in the fact that generations of people will benefit from the medical advancements that come out of it.

And the Top 5 MedFriendly Blog Entries in November Were...

Below are the top 5 most popular blog entries for the month of November. This is a monthly feature of the MedFriendly Blog and gives readers a chance to catch up on the most popular blog entries they may have missed. Overall, another terrific month for the MedFriendly Blog. Please post a comment if you have blog entry suggestions. Here is the Top 5 list:

1. The SHOCKING Ingredients In A McRib Sandwich: This popular entry had 253 views. A must read if you are even thinking of ordering the McRib.

2. 10 Easy ways to Improve Your Mood and Outlook on Life: Check out this entry to put a smile on your face and add a little pep to your step. 102 page views this month.

3.  Does Your Kids Cereal Contain BHT or BHA – An Ingredient on Jet Fuels? Mine Did: My cereal cabinet looks a lot different since I wrote this. 99 page views this month.

4. Woman Injects Cement& Tire Sealant Into Woman’s Backside: The pictures tell the story. 92 page views this month.

5. Why Neuropsychological Testing is Helpful in Dementia Evaluations: As a neuropsychologist, this makes me happy that 91 page views were recorded and it cracked the Top 5.

Radiation from Full Body Airport Scanners: Why I Opt for the Pat Down

X-rays are forms of radiation that are strong enough to damage and mutate DNA in such a way that it causes cancer. Many people believe that they are only exposed to radiation when they go to the dentist and get an X-ray. However, we live in a radioactive world, with radiation all around us such as in the very air we breathe. Our bodies are exposed to radiation every day. One source is cosmic rays from outer space and another is food. That’s right…food. All organic food (e.g., carrots, bananas) contains a small amount of radiation from radioactive potassium and radium. Even water contains small amounts of radiation.

Most human exposure to radiation is from medical procedures such as X-rays, CT scans, and mammograms. Radiation can be measured in a unit known as millirems. The According to the U.S. Nuclear Regulatory Committee, the average American is exposed to 620 millirems of radiation, with 310 miilirems coming from the environment. If you receive a whole body CT scan, you receive 1000 millirems of radiation, which is much more than the yearly exposure. Get a CT scan of the chest and you received 700 millirems, again more than the yearly dose. Dental x-rays? Well, they only give you 1.5 millirems. However, there is level of radiation that is technically “safe” since the health effects of radiation are cumulative. That is, the more radiation you are exposed to, the worse of an effect it has on your health.

So, there is some degree of radiation exposure you will get no matter what. But why expose yourself to any extra radiation? One source of needless radiation you can avoid are full body scanners at airports. These are known as backscatter scanners. It had traditionally been thought that these scanner expose you to very low levels of radiation (e.g., .005 to .01 millirems). The Transportation Safety Administration insists this level is safe (e.g., 1000 such scans is equal to 1 chest x-ray) , but the non-profit investigative journalism organization, ProPublica, insists that the U.S. government glossed over cancer concerns as it rolled out these scanners and that the radiation exposure level is much higher. Researchers at Columbia University have said that the machines emit 20 times more radiation that originally estimated. The Inter-Agency Committee on Radiation Safety indicated that pregnant women and children are particularly at risk by these scanners.

On 11/14/11, the European commission announced new policy that they would ban these types of scanners due to concerns about health and safety. Instead of using X-ray scanners, they are replacing them with millimeter-waver scanners, which use low energy radio waves. Due to the low energy, these scanners do not have the power to cause genetic mutations and thus should not cause cancer. On 11/21/11, the head of the TSA reneged on his prior plan to re-study the safety of the scanners, stating they were safe. Not being a radiation expert, I really don’t know who is right. But I do know that I can at least opt out of these scans and that is what I did the last time I went to the airport. The result is a pat down but I found the whole experience easy to deal with. At least I know  did not expose myself and my family to needless radiation. And just in case you were wondering, metal detectors at the airports do not expose you to x-rays or damaging forms of radiation.

Elderly Woman with Dementia Allegedly Waterboarded by Staff after Dispute Over Ice Cream

Besides abuse of children, abuse of the elderly is one of the most despicable crimes in society. A shocking example of this was revealed in a story about two nursing home employees who allegedly putting an elderly patient (age 89) with severe dementia through a mock drowning with a shower spray. Why? Because they got into an argument with her over…ice cream.  Pathetic.

Fortunately, a co-worker witnessed the abuse and reported it. But it makes you wonder what would have happened if the witness did not report it or if there was no witness. If the patient had severe dementia, she likely would not have the cognitive abilities to report the crime and if she did report it, it is likely that no one would have believed her due to her medical state.

Having more staff present in nursing homes increases the chances that a witness will be present. Having a witness present, though, is not enough if the witness is scared to report what he/she has seen. This is why hospitals, nursing homes, and other medical facilities should have anonymous abuse reporting mechanisms that are well publicized.

It is ideal to have responsible family members present to visit the elderly in medical facilities because staff would be less likely to abuse a patient who they know have family members who are keeping an eye on the patient and have a close relationship with hospital workers (particularly those in senior positions) and who are advocating for them. Unfortunately, patients with no family members who are isolated are the ones most vulnerable to abuse because they have no one to look out for them.  Checking over a loved on for unexplained bruises, cuts, or other marks on the body should be done regularly. Reasonable explanations (e.g., slip and fall) for marks on the body (e.g., black and blue) should have some confirmatory documentation in the medical record. Suspected abuse should be reported immediately so that it does not continue to occur.

Woman Injects Cement & Tire Sealant Into Ladie's Backside

When I was in training, I remember once evaluating a former physician who had lost his license partly due to finishing his surgical procedures with wood screws from Home Depot instead of standard surgical screws. In addition, he used rubber cement instead of the standard surgical adhesives. He proudly defended his actions and stated that the wood screws worked better and saved him money. He did not seem to have any regrets over what he had done, despite the fact that patients were harmed. This was the case that came to mind today when I read about a woman who had gone to a person who she thought was a plastic surgeon to get a curvier body. Given that plastic surgery is expensive, she tried to save money and saw someone referred by a friend. After paying $700, she reportedly received toxic injections of cement, mineral oil, and flat tire sealant! This caused her to develop serious medical problems. You can read more about this story here.

While trying to save money is generally a good idea, it is not a good idea when it comes at the expense of picking someone not qualified to provide the desired medical service – in this case, plastic surgery. When trying to find a new doctor, I have put together a brief set of tips on how to do this in a way to minimize dealing with a charlatan. One of the tips I did not mention in that article was to walk away if the person does not physically appear professional to you. This is admittedly subjective and starts to enter into somewhat controversial territory, but if I am going to a plastic surgeon and she walks in with giant feathers dangling from her ears, I am likely walking away. I say this based on a picture of the person (Oneal Ron Morris) above who allegedly posed as a plastic surgeon and injected the concoction of toxic substances. Of course, I don’t know if she was wearing these earrings or some other odd form of apparel when the patient met her, but if so, it is a red flag.

I have used the word “she” above but “he” is the more accurate word to use because Morris was a man who identifies as a woman. Given that Morris was allegedly presenting as someone who can improve another person’s body curvature, I would personally be concerned if I saw that the doctors own body curvature looked like this.

When seeking a plastic surgeon, it is best to have one who is board certified because this provides an additional safety net. A board certified doctor (from a reputable organization) is one who has been vetted by his/her peers to have the appropriate training and education to perform a specialized service and has passed a rigorous examination(s) in the particular specialty area. For physicians, the main board certifying authority is the American Board of Medical Specialists, which oversees the American Board of Plastic Surgery.

Another tip is to find out if the plastic surgeon has privileges at the hospital. This is important because hospitals do background checks on their doctors. If the doctor says he/she has hospital privileges at a particular hospital, call the hospital and confirm this if you have doubts.

Why Healthcare Providers Should Not Hug Their Patients

Imagine this scenario. You are a male health care provider and you complete an evaluation of a woman close to your age. You establish good rapport as you always do, she laughs at some of the same jokes you make with all patients, and she expresses delight that you are listening to her problems (unlike those other providers she says she has seen), feels you are helping her, and is looking forward to the next appointment with you. At the end of the visit, she walks up to you and opens her arms to give you a hug. What do you do?

Many may feel that they do not want to offend the patient and so they go on and give the hug even though they may not feel comfortable. In my opinion, this is the wrong choice. For starters, hugs, unlike handshakes, are sometimes intimate gestures. You hug your spouse during intimate moments but you do not shake your spouse’s hand. A hug is much more informal compared to the handshake, which results in a slippery slope.

As health care providers who need to be objective, it is important to maintain some boundaries that maintain the doctor-patient relationship (add any healthcare provider you want to in place of doctor). Hugging patients blurs those boundaries. For example, it will be more difficult to tell patients news they may not want to hear (but need to hear for their sake) if they begin to see you more like a friend or family member than a professional.

Another problem is that in this day and age, concerns about lawsuits and patient complaints are more prevalent than ever. The concern in this case is that the meaning of a hug can be misconstrued by a patient as meaning something more intimate than was intended. In addition or alternatively, some accidental touching to sensitive body area can occur during a hug that is misinterpreted by either person. This can raise concerns of sexual harassment as the person can claim that the touch was unwelcome. This is more likely to occur if the health care provider initiates the hug. It is more likely to occur when the hugger is a male health care provider and the recipient is a woman or a child. Female to female and female to child sexual harassment claims are much less common. This means that female health care providers do not need to worry as much about a sexual harassment claim based on hugging patients but the crossing of professional boundary lines issue remains. 

When a patient tries to initiate a hug, my response is to simply say in a nice and respectful way that I am not allowed to hug patients because it crosses a boundary line. Then I offer my hand for a handshake. This can admittedly result in some slight embarrassment on both sides, but it is better to be safe than sorry. This solution is better than one that a supervisor once told me he used, which was to say “I think you need to get your hugs from somebody else,” which sounded too rejecting to me. If the patient insists on hugging you and lunges on you, it is best to document this clearly in your clinical note and explain that this cannot occur again.

The advice I provided above also applies when interacting with patient family members. That being said, there may always be a rare exception depending on the case and circumstances.

10 Ways to Protect Your Children from Child Sex Offenders

Tonight, I sit here in Syracuse, NY, shocked to hear sexual abuse allegations against long-term Syracuse University assistant men’s basketball coach, Bernie Fine. You see, I am a HUGE Syracuse Orange Fan. I do NOT want to believe this is true. Head coach, Jim Boeheim says the allegations are false but we will need to await the results of the police investigation.

For anyone watching the news in the past few weeks, these allegations come in the wake of the Notre Dame child sex abuse scandal that rocked the country. People have once again been reminded about the dangers of sexual abuse. The ways sexual predators operate were best exposed, in my opinion, during the recurring MSNBC special known as “To Catch a Predator” by Chris Hansen.  In it, Hansen documented how sexual predators lured child victims online and came to their home to engage in sexual relations, thinking that the children’s parents were gone.

Regardless of whether the allegations against Bernie Fine are true, people must be wondering what they can do to keep their children safe some sexual predators. A few suggestions are listed below.

1. TALK TO YOUR CHILDREN: If a child is inappropriately touched, he/she needs to feel comfortable discussing it with you. It is an uncomfortable topic for sure, but if you have an established relationship with your child such that the child can feel free to come to you and discuss any topic, good or bad, the child is more likely to come forwards if something inappropriate occurs. From a young age, children need to be told that if anyone touches their private parts or touches them in a way that makes them feel uncomfortable that they need to tell you about it as soon as possible. Make sure your children know never to go somewhere with a stranger and that if a stranger grabs them, that they should try to scream, get away, and run to an area of safety. Let your child know in advance that if a predator threatens to harm the parent if he/she tells of any abuse, that the parent will actually be ok and to tell someone anyway.

2. SEARCH ON-LINE SEXUAL OFFENDER REGISTRIES: Check your state’s online sexual offended registry, such as this one in New York. These registries allow you to see if there are sexual offenders living in your area, what their names are, where they live, and what they were charged with. Once you know where they are, you can make sure your child knows not to go there.

3. BE VIGALENT: Be mindful of where your children are. Do not let them stand at a bus-stop alone. Do not let them spend alone time with adults you do not know. Do not let them veer away from you in public places, such as the mall.

4. COMBATING GETTING LOST: If your children get lost in a public place, they can become easy pretty for a sexual predator. Make sure they know what to do if lost, such as seeking out a cashier or police officer and providing that person with a name, address, and phone number.

5. SPEND TIME WITH YOUR CHILDREN: Sexual predators try to prey on the most vulnerable children, which includes people who do not see their parents much. Thus, if you spend frequent time with your child, that is time that no one else will be doing so.

6. COMPUTER AND PHONE USE: Be aware of what websites your children are viewing (e.g., check the history log), install filters that prevent visits to adult websites, limit, ban, or closely monitor participation in social media sites (Facebook, Google+, MySpace, Twitter) based on the child’s age, and tell them to not develop relationships with strangers on-line, give out their phone number/address, or meet strangers from on-line (or the newspaper) in person. Make sure your child knows that strangers on-line may pretend to be people they are not. Monitor text messages and pictures your child sends for inappropriate content.

7. DO NOT GET OVERLY COMFORTABLE WITH STRANGERS: Sexual predators are typically charming. You may believe that you know the person and feel comfortable because he/she is nice, but neighbors, babysitters, priests, teachers, coaches, and even family members can be sexual predators in your midst. Do not let your guard down and be very careful who you chose to leave your child alone with. Do not allow taps on the buttocks, touching of the legs, tickling, or other inappropriate touching to go on if your feel it is inappropriate.

8. USE FEMALE BABYSITTERS: Sexual predators are almost always men. Thus, your child is likely to be safer with a female babysitter.

9. TEACH SELF DEFENSE: Teach your child some self-defense strategies to use if a sexual predator makes threatening physical advances to a child.

10. SECURE YOUR HOME: Keep doors and windows locked. This is crucial. Many sex offenders state after being caught that if a door entering the house was locked that he/she would likely have moved on. If you can, have a dog or dogs that bark when strangers come.