A Discussion About Wilderness Medicine – Hawaii Public Radio January 6, 2014

Here’s a link to a discussion I had with Dr. Kathy Kozak about Wilderness Medicine on Hawaii Public Radio on 1/6/14.

 

Listen Here:

 

Happy New Year,

Scott Rennie, DO

 

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30 Things to think about when moving to Hawaii

Honl-Beach-1Many of my friends and family members ask me about what it’s like to live in Hawaii.  There are many things that are great, and a few things that you might not have considered.  I decided to write down a list of things that I learned about after moving to Hawaii.

1)   You will become instantly popular with your friends and family who live on the mainland.  Try to get a place with a spare bedroom so you can accommodate visitors.

2)   If you have a pet, consider getting your animal’s rabies vaccinations up to date well in advance of moving.  The animals need to be current on their vaccinations and they also need to get blood work done to prove that they have built up immunity to rabies.  It can take up to 4 months to get this process done and if you prepare ahead of time, it might save you being away from your pet.

3)   If you want to ship your pet to Hawaii from the mainland, you’ll also need to have your pet given a good bill of health from your local veterinarian.  Some airlines don’t allow certain dog breeds to fly in the hot summer season (think Boxer or dogs with Brady cephalic heads).  It’s also expensive to ship them and if they’re a larger breed, they will likely need to ride in the cargo hold and my dogs and I aren’t too fond of that idea.

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4)   The weather can be great, but it isn’t always sunny.  Sometimes we have VOG (Volcanic Fog) from the active volcano on the big island that clouds the skies.  It looks similar to smog that you might see in LA or another big city.  If you have allergies or asthma, you might benefit from bringing your eye drops, antihistamine or an albuterol inhaler with you.  It can rain very hard suddenly and without much warning if you live in certain areas of Hawaii.

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5)   Traffic in Honolulu and Waikiki can be horrible.  We’ve all heard this before, but I moved from Seattle and thought we had bad traffic there.  Ha!  You might also consider that many people on the roads are visiting from other places (even other countries) and aren’t familiar with the roads.  Also if you drive in rural areas like the famous road to Hana, be prepared for some small roads, one-lane bridges and some areas where there’s not any protection between you and falling over a large cliff beside you.  Drive carefully!

 

 

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6)   The food is amazing.  If you’re visiting Honolulu and enjoy trying different kinds of foods – Asian, Hawaiian, Portuguese and a fusion of many others, you won’t be disappointed especially if you have a chance to get outside of Waikiki.  The restaurant selections on islands other than Oahu might be a less abundant however.

7)   It’s expensive – gasoline, groceries, eating out, movies, and many other things can cost quite a bit more than on the mainland!  You knew that already though, and as you learn where to go shopping (think Costco if there is one on the island you visit) you will learn how to adjust. If a grocery store offers a membership or discount card, get it!  I usually don’t spend as much money on “extras” here though.  When I want to enjoy a day off, I usually don’t spend any money visiting the beach!

8)   Things rust and wear out quickly if you don’t take care of them.  Wash your car once a week if you can, then wipe it dry so you don’t get hard water spots.  Then wax your car to protect the clear coat!

Unprotected-paint

9)   Be patient!  Sometimes things move slower – traffic or lines at the cash register for example. It’s a fact of life. Try not to get frustrated; it will make your day more enjoyable.

10)  Get to know people who’ve lived here for a long time.  They can show you places and teach you things about the islands that you will not learn in a book or blog post.

11)  If you ship a car to Hawaii, it’s a process to get the registration changed to Hawaii.  Just take a day off work and plan on spending the whole day to get this done.  Even if you have car insurance from a large company like State Farm or Farmer’s, you’ll need to get a local agent.  Once you have your auto insurance agent and your new insurance ID card for Hawaii, you can go get your car safety inspected.  These inspection stations can be busy, and they’ll check the tint color of your windows, your signals, mirrors and if your car checks out, they will give you a slip of paper that you can bring to the department of licensing.  You may have to wait in line at the DOL for half a day, so be prepared.  Bring something to read and some snacks and don’t forget to take a number.  Licensing your car in Hawaii might be more expensive than in your Mainland State.  Once your car is registered, you need to drive back to the safety inspection office and have them stick a safety sticker on your car.  I told you it was a process didn’t I?

12)  It can be hot and muggy, especially in the summer months.  There are days when the trade winds aren’t blowing or the “Kona” winds blow up from the south and the weather can be a bit uncomfortable for those of us who are not used to the humidity.  The trade winds usually keep it pleasant because they blow a cool breeze over the islands but don’t count on that 100% of the time.  You may want to have an air-conditioner where you live.  Do you pay the electric bill?  See #7 about things being expensive in Hawaii – including electricity.

13)  There are centipedes, cockroaches, scorpions, geckos, lots of different birds, frogs, and of course mosquitos.  I don’t mind the geckos, birds and most frogs – I enjoy them except when they occasionally keep me awake at night.  Centipedes, scorpions, cockroaches and mosquitos I don’t like however I learn to take proper precautions to avoid them.  Take your trash bags outside every night before you go to bed!

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14)  Be persistent if you’re trying to reach someone be telephone or email.  I learned that sometimes people don’t get back to you right away.  If you’re trying to rent a house or apartment, or conduct any form of business be persistent (not annoying) because sometimes people in Hawaii might not call or email you back immediately.   Because this can be frustrating for me sometimes, I try to get back to other people as quickly as possible.

15)  You don’t need as many clothes.  Pick out a few pairs of shorts, aloha or T-shirts, some slippers, sunglasses and a hat and you’re ready for most days. On work days, wear some nice lightweight pants and shoes.  Even most business professionals don’t wear a tie (even most doctors) but you’ll want to check with your employer on their standards.  You might need one lightweight sweatshirt or sweater but unless you’re spending lots of time on Haleakala, Mauna Kea or one of the other mountains you probably won’t need a coat.

16)  Wear sunscreen every day.  The sun here is intense and you can get burned very quickly.  I can’t tell you how many tourists that I’ve treated for sunburns while working as a physician in Hawaii.  Melanoma, and carcinoma of the skin are also very common.  You’ve probably seen people who have wrinkly skin and walk around with amazing suntans all the time but you don’t want to be one of them.

17)  Be aware of scooters and motorcycles.  They’re sometimes hard to see and are very common in Hawaii.  You might be more aware of them than you want to be if you hear them racing down Ala Moana Boulevard at 1am.

Lahaina motorcycles

18)  Watch what you eat.  As I mentioned in #6, the food is great but if you eat too much local food like rice, macaroni salad, lau-lau, Portuguese sausage, and Loco-Moco you might end up gaining weight quickly.  We have more diabetic patients here in Hawaii than anywhere else I’ve worked.

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19)  Flying from one Hawaiian island to another can be expensive.  I’ve been to all of the major islands (except Niihau and Kahoolawe) and I can say that the cost per mile of flight is more expensive in Hawaii and anywhere else I’ve been.  A one-way ticket to Maui from Oahu is around $100 per person unless you find a special deal.

20)  Having a small car might be an advantage especially if you live on Oahu because parking can be difficult, and gas prices are high.

21)  If you buy things on the Internet, be aware that shipping prices can be extremely expensive!  You may often pay more to ship an item to Hawaii from the mainland than what the price of the item is.  Look for free shipping or have things shipped to the mainland and bring them with you if you travel back and forth.

22)  You will hear people talk pidgin – the local language that is actually a mixture of many different languages.  You may not understand it but if you live here long enough, you will learn some of the words.

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23)  There are natural disasters such as hurricanes and tsunamis here that you might not be used to on the mainland.  Register yourself and your family with the emergency contact registry and get a weather radio.  Consider getting a ham (amateur) radio license to be able to communicate in a disaster.

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24)  Hawaii does not have daylights savings time.

25)  Don’t leave items in your car in plain sight.  This isn’t just in Hawaii but anywhere.  I’ve heard many stories about tourists who arrive in Hawaii and drive right to Costco from the airport with their luggage in their car only to come back from shopping to find everything gone.

26)  Each island in Hawaii is different.  I’ve met so many people who have been to Hawaii year after year and they come to the same island and often stay in the same place.  Each island has it’s own charisma and things about it that make it unique. Kauai is the most beautiful place I’ve been, Oahu has something from everyone, Maui has a unique valley and some of the best windsurfing in the world, Lanai has a couple great resorts and is very expensive to visit, Molokai has awesome sea cliffs and also has Kalaupapa, a place where patients with leprosy (Hanson’s disease) were quarantined and the Big Island has an active volcano and some of the most amazing places to star-gaze in the world.  Check them all out before you decide where you want to live.  Learn the difference between the Big Island of Hawaii and the island of Oahu where Honolulu and Waikiki are.

27)  Living in Hawaii is not a 24/7 vacation.  I’ve worked longer hours in Hawaii than any other job since residency.  There are some weeks that I never get to the beach.

28)  The school system is different than the mainland.  I don’t have children, but if I did I would learn all I could about public versus private schools and where the best schools are in Hawaii and take that into account when deciding where to live.

29)  Some people get “island fever” also known as “rock fever.”  They have a feeling of being trapped on the island.  I’ve never experienced that feeling but I recommend that you try living in Hawaii for a few months before deciding that you want to up-root your family and move here permanently.

30)  This list is a work in progress and will change as I live here longer.

I hope that you’ve found some of this information useful.

Aloha!

Scott Rennie, DO

It’s “Voggy” out there… What are the long term effects of vog (volcanic pollution)?

shutterstock_153524036Vog is a form of air pollution that results when sulfur dioxide and other gases and particles emitted by an erupting volcano react with oxygen and moisture in the presence of sunlight. The word is a portmanteau of the words “volcanic” and “smog“. The term is in common use in the Hawaiian islands, where the Kīlauea volcano, on Hawaiʻi Island (aka “The Big Island”), has been erupting continuously since 1983. Based on June 2008 measurements, Kīlauea emits 2,000 – 4,000 tons of sulfur dioxide every day.

Vog poses a health hazard by aggravating preexisting respiratory ailments, and acid rain damages crops and can leach lead into household water supplies. The U.S. Geological Survey’s Hawaiian Volcano Observatory is closely monitoring gas emissions from Kilauea and working with health professionals and local officials to better understand volcanic air pollution and to enhance public awareness of this hazard.

Like smog, the presence of vog reduces visibility. Moisture in the air causes vog particles to enlarge, decreasing visibility still further. On the Island of Hawai`i, people often turn their headlights on during daylight hours when driving in vog, and vog sometimes limits visibility for air traffic.

By Roger Mari –

KEWALO BASIN (KHNL) – Months of heavy vog might have some wondering what the long term affects the sulfur oxide in the air has on our health.

A respiratory expert shared information on a study of volcanic pollution.   The results might come as a surprise to many.

Leading the ongoing research is Doctor Elizabeth Tam.  She believes volcanic pollution or vog can trigger an asthma attack in people including children already diagnosed with the condition.

“We don’t think volcanic air polution actually causes asthma,” said Dr. Tam.

The March eruption of Kilauea’s Halemaumau crater sent large amounts of sulfur dioxide into the air making for more voggy days this year.   Not ideal for photographs, jogging and other outdoor activities, but the vog provides the perfect lab for research.

“There have been times we’ve been in the schools studying, doing our thing and the air polution is much more than before,” Tam said.

The group of children were first examined before they were teens.   Voggy days had the usual effects on them as they would on those who were otherwise healthy.

“We get more of the upper respiratory effects nose, eyes, stinging throat etc., but it doesn’t appear to be asthma,” said Tam.

Researchers including Doctor Tam, will continue the study on the select group of children which began six years ago.

“We’re actually studying the long term effects of the kids, so we continue to study the children which is good,” she said.

So far vog does not appear to be the cause of asthma in the select group of big island children.

But one thing is certain, island residents could be living with vog for years to come.

The idea is to study the children as they grow up.   They were as young as 12 to 14 when research began.

The plan is to monitor their respiratory conditions until they are 18.

Lightning Injuries and Prevention

shutterstock_15532345I’ve met a few people who have been struck by lightning and lived to tell about it, and I thought I’d pass along some information about lightning injuries and how to prevent them.  Much of this information comes a recent class in Advanced Wilderness Life Support (AWLS)

Interesting facts about lighting:

•  Lightning strikes are the second leading environmental cause of death (behind flash floods) in the United States, with an average of 50-300 deaths per year.

•  There are 3-5x as many people who are struck by lightning and survive than die.

•  Nationally, there are 20 million cloud-to-ground flashes detected annually.  In some summer afternoons, more than 50,000 flashes per hour are detected.

•  The most common months of injury are June, July and August, although lightning strikes may occur during any time of year (even in snowstorms).

•  The most common time of day for deaths due to lightning strikes is in the afternoon between 3pm and 6pm local time and this is because of the sun heating the ground which causes vertical cumulus clouds to form that may be tall enough to produce lightning.

•  Florida is the worst state for lightning deaths with nearly 2x as many deaths than the next state.

•  The most dangerous times for a severe lightning strike are before the storm appears and after it has passed.

•  Lightning may travel nearly horizontally as far as 10 miles in front of a thunderstorm and seem to occur out of a “clear blue sky,” or at least when it is sunny.

•  Lightning does commonly strike twice in the same place.

•  A lightning bolt is a unidirectional massive current impulse carrying up to 30 million volts.

•  A lighting bolt is about 6-10cm in diameter, but the ionized sheath is much broader (up to 20cm).  The temperature of the sheath is usually around 8,000 degrees centigrade.

•  There is no need to be concerned about getting shocked or injured by rescuing a person who has been struck by lightning because lighting does not leave a residual charge on a victim.

•  Contrary to popular myth and what is seen in cartoons, deep burns are unusual after lightning injury.  At the most, some minor second-degree burns may occur from superheated metal objects.

Mechanisms of injury:  People can be injured by lightning in several ways:

1)   Direct strike:  a person is hit directly by a bolt of lightning and this happens most commonly with people who are caught in the open and unable to find cover.  This is the deadliest type of strike.

2)   Side splash:  lightning directly strikes another object such as a tree or building, but the current flow, which seeks the path of least resistance, jumps from its original pathway onto the victim.  This is the most common cause of lighting injury. Side splashes may also splash indoors from metal objects such as plumbing or telephones and may even occur from person to person when several people are standing close together.

3)   Contact exposure:  occurs when a person is holding onto or touching an object that is either directly hit or splashed by lightning.  The current passes through the object onto the victim.

4)   Ground current or step voltage:  lightning strikes the ground or a nearby object and the current spreads through the ground.  If a person has one foot closer to the strike than the other foot, an electrical potential difference between the two feet may occur and the current may pass up one leg and down the other leg.  This is a common mechanism for several people being injured at the same time.

5)    Blunt trauma:  injury due to the impact of the concussive force of the strike itself or from being thrown due to the extreme nature of the muscular contraction from the electrical charge.

How lightning affects the body:  injuries occur from a “short circuiting” of several of the body’s electrical systems as well as the more direct trauma and indirect trauma due to the muscular contraction and being thrown.  The most common cause of death in a lighting strike victim is cardiopulmonary arrest.

Treatment:  I think it’s important for everyone to be trained in CPR.  In lightning victims, we usually perform reverse triage and initiate CPR on those patients who are pulseless and apneic (not breathing) before caring for those who have spontaneous signs of life.  This is because those with no spontaneous breathing or heartbeat may recover and will require assisted breathing until their respiratory drive returns.  Assisted breathing for these patients may prevent a secondary cardiac arrest due to low oxygen intake.  If a victim does not regain a pulse within 20-30 minutes we usually then discontinue the resuscitation.  The patient will need evacuation to the nearest medical facility even if the individual does not have any overt evidence of damage.  There is a high likelihood of some sort of injury that is not served best by staying in the outdoors.  Splinting fracture and spinal precautions is necessary.

Avoiding lightning injuries:

1)   30-30 Rule:  The first “30” is when the time between seeing the lightning and hearing the thunder is 30 seconds or less, then people are in danger and should be seeking appropriate cover.  The second “30”:  outdoor activities should not be resumed until 30 minutes after the last lightning is seen or last thunder is heard.

2)   Seek shelter in a substantial building or in an all metal vehicle:  small shelters such as golf, bus and rain shelters may increase a person’s risk of being struck due to side splash as the lightning flows over the building.  All metal vehicles are safe because the metal will diffuse the current around the occupants to the ground.  A convertible is not a safe alternative.  It is a myth that rubber tires provide insulation.

3)   If you are caught in a storm outside without a safe building or vehicle:  Stay away from metal objects and those items that are taller than you.

4)   Avoid areas near power lines, pipelines, ski lifts, and other large steel objects.

5)   Do not stand near or under tall isolated trees, hilltops, or at a lookout or other exposed area.

6)   In a forest, seek a low area under a growth of saplings or small trees.  Seeking a clearing free of trees makes a person the tallest object in the clearing.

7)   If you are completely in the open, stay far away from single trees to avoid lightning splashes and ground current.

8)   If you are on the water, seek the shore and avoid being the tallest object near a large body of water.

9)   If indoors, avoid open doors, windows, fireplaces and metal objects such as sinks and plugged in electrical appliances.  Do not talk on the telephone, as the telephone lines are not usually grounded like electrical wires.

References:  Advanced Wilderness Life Support Handbook

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Blood Clot in the Leg – All about the Deep Vein Thrombosis (DVT)

shutterstock_89651743http://www.dvtforum.com/index.asp?action=start

A few days ago a patient came into the clinic with complaints of pain in the back of his knee after spending hours driving his car back to Washington from the east coast.  He didn’t recall injuring his leg or knee and told me that the pain was worse when he starts walking.  He also noted some swelling in the leg and ankle.  I became concerned about the possibility of a blood clot (also called a deep vein thrombosis or DVT) in his leg after hearing about his long journey because sitting for extended periods of time in a car or on an airplane are big risk factors for a deep vein thrombosis.  After the ultrasound confirmed a blood clot in his left leg, we started him on the treatment and he is doing great today.

A blood clot (also called a thrombus) can be very serious and even life threatening if it breaks and travels through the circulatory system.  If that happens, the blot clot (now called an embolis to indicate that it broke off from the main clot and is traveling through the veins of the body) can lodge in the lung and cause a pulmonary embolism (PE) which is a serious condition that causes over 50,000 deaths a year in the U.S.A.

A deep vein thrombosis (DVT) is a problem where a blood clot is created inappropriately within the vein.  Most commonly these veins are in the “deep veins” of the leg, pelvis, or thigh.  The thrombus can block or partially block the blood flowing through the vein and cause pain and swelling.

Symptoms:  These may or may not all be present:

1)      Pain – usually in one leg, or knee

2)     Swelling in that leg or knee

3)     Warmth and redness in the leg or knee area

Diagnosis:  If a medical provider suspects that you might have a DVT, there are certain tests that can be done to look for this including:

1)      Compression ultrasonography (ultrasound) which uses sound waves to allow the visualization of the blood flow through the veins of the leg.

2)     D-dimer is a blood test that is often elevated in people who have a blood clot.  It can also be elevated for other reasons, so an elevated D-dimer does not tell us that a patient has a blood clot, but if the D-dimer is not elevated and  the risk factors are low, there is less chance of the patient having a blood clot.

3)     MRI uses a very strong magnet to create photos inside the leg and is expensive so it’s not the first choice the diagnose blood clots.

4)     Contrast venography is when a small tube (called a catheter) is inserted into the vein and a liquid that shows up on x-ray (we call this contrast) is injected through the tube while xray is used to visualize the blood flow of the contrast through the vein.  We usually prefer to use ultrasound, but this test can be helpful when ultrasound is not available.

Risk factors for DVT:

1)      Some people have a genetic problem called thrombophilia which causes blood to clot more easily than it should

2)     Cancer

3)     Smoking

4)     Heart failure

5)     Pregnancy

6)     Being overweight or obese

7)     Increased age

8)     Having had a DVT or PE in the past

9)     Certain kidney problems

10)  Medications such as birth control pills or hormone replacement therapy

11)  Recent surgery – especially involving the knee, hip or pelvis

12)  Trauma – such as a fall or deep bruise where the blood vessels may have become injured

13)  Sitting for long periods of time such on a long flight or a long drive in a vehicle.  We also think about this for elderly patients who don’t move around very much

Treatment:  The goal in treating a DVT is to prevent the blood clot from dislodging or breaking off and becoming an embolism that could lodge into the lung (pulmonary embolism).  We also want to prevent the clot from getting larger or new clots from forming.

Medications can be used to prevent new blood clots from forming(anticoagulants), and other medications can be used to dissolve a blood clot (thrombolytic).  Most people might think that the primary treatment would be to dissolve the clot using thrombolytic therapy, however this is usually not the case.  The body has natural substances to dissolve blood clots that are formed inappropriately in blood vessels and we usually prefer the body to do this naturally while assisting by giving medications to prevent new blood clots from forming.  Anticoagulant medications such as warfarin or heparin are the most common agents used to treat patients with DVTs at this time.  For patients who continually develop blood clots despite being on medications or who cannot take the recommended medications, a filter might be inserted into one of the largest veins in the body (the inferior vena cava) to block the circulation of blood clots.  We strategically place the filter so that if a blood clot forms, it is not allowed to reach the lungs.

Prevention:  For patients at high risk of developing a blood clot such as a patient who just had surgery, or someone who has cancer, they might be started on anticoagulant medications to decrease the risk of a blood clot.  Some patients are fitted with inflatable compression devices that are worn on the legs and periodically fill with air and put compression on the legs and work similar to how an electronic blood pressure cuff inflates.

If you or someone you know is having symptoms that you think might be related to a blood clot or DVT, I recommend that you have them evaluated immediately.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Wilderness Dentistry

shutterstock_101677420I recently returned from a wilderness medicine conference in Whistler, British Columbia.  Eric Johnson, MD gave a great talk on dentistry in the wilderness so I give him credit for much of the information presented here.

On wilderness backpacking adventures there are many possible dental problems.  Many patients have dental crowns or veneers that get broken.  Dental cavities or broken teeth can often be spotted before leaving for a three week journey, so it’s important to get a dental pre-trip exam to look for problems before departure.

Some of the most commonly encountered dental problems in the wilderness are:

1)  Cracked or dislodged fillings

2)  Inflammation of the gums around the tooth (the piece of popcorn stuck between the tooth and gum)

3)  A cracked tooth or crown

4)  A chipped tooth

5)  Trauma causing a completely knocked out tooth (exodontia)

6)  Dental abscess

Treatment:  Treatment of dental problems should always be attempted by someone trained in dental surgery, however in an emergency situation in the wilderness a dentist may not be available.  Adequate lighting is essential when treating dental problems in the backcountry.  I like to carry a headlamp so that my hands are free to work with the patient.

Cavit is a temporary filling material that is self curing that you can bring with you and is very helpful to treat problems such as dental crown or filling that has broken or come off.  It comes in small tubes or containers and is similar in consistency to silly puddy but hardens and can be very helpful to reduce dental pain from exposed pulp/nerve.

If a tooth needs to come out, it can be removed in the back country but it should only be attempted by someone with experience in this procedure.

Exodontia:  The extraction of a tooth.  If the tooth is not extracted in its entirety or there is a root that does not come out they can get infected.  Extracting a tooth is not as simple as simply pulling it, there are many possible complications of tooth extraction such as:

1)  Accidentally removing the wrong tooth  – it’s easy to do because pain from one tooth can feel like it’s coming from somewhere else in the mouth

2)  Breaking a tooth while pulling it – can cause severe abscess

3)  Excessive bleeding

4)  Dry socket – extreme pain after the extraction

Extrusion:  Dental trauma causing the tooth to get knocked out completely.

If a tooth gets knocked out, it’s important to protect the tooth and try to get it re-implanted as soon as possible.  If re-implantation is done within 20 minutes there is usually a very good chance that there will be a good outcome.  If it’s longer than 1 hour, there is less chance that the tooth will live.  Some tips on what to do if a tooth gets knocked out:

1)  Keep the tooth moist with saliva (keep it in your mouth)

2)  If there is not a dentist in the back country with you, a medical provider may be able to anchor the tooth into the socket using a figure of eight stitch (suture).  I have also heard that dental floss can be used to tie one tooth to another.

3)  Do not chew

Dental Blocks:  Sometimes it can be very helpful to provide local anesthesia using a dental block to help alleviate pain.  On the upper teeth, injecting on either side of the tooth (around the tooth) with lidocaine may provide adequate analgesia rather than having to do full dental block.  Anesthesia for teeth on the lower jaw (mandible) is more difficult and may require a block.

20% Benzocaine gel can decrease the discomfort at the injection site and is a good item to have in your dental kit.  It can also be used on tongue or lip ulcers or canker sores.

Equipment:  1” 27 gauge needle, 3ml syringe, 2% lidocaine with epi (or similar agent)

Back Country Dental Kit:  Here are some items that you might consider taking with you into the back country if you are the medical officer on an expedition with a group of hikers:

1)  Number 150 or 151 universal extraction forceps

2)  Straight elevator

3)  Mouth mirror

4)  Orabase with benzocaine

5)  Orthodontic wax

6)  Dental floss

7)  Dental syringe

8)  27 gauge needles with anesthetic

9)  Cavit or IRM for temporarily filling/sealing a tooth

10)  #11 blade scalpel

11)  20% benzocaine gel

If you’re in the Seattle area and are looking for an excellent dentist, I highly recommend Robert Odegard, DDS.  He has been my dentist for more than 20 years and has excellent skills and his staff are great.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Pulmonary Embolism (PE) – Blood Clot in the Lung

shutterstock_94626226A patient who regularly competes in Iron Man Triathlons came into the clinic tonight with complaints of pain with taking a deep breath.  She had coughed up some blood once today and complained that it hurts when she takes a big breath in.  She is an athlete and remembered running in a race about three weeks ago and developed pain in the right calf and behind the right knee.  That pain has been improving over the last few weeks.  As you can probably guess by the title of this blog entry, she had a blood clot in her lungs.  Actually she had large blood clots called pulmonary emboli in both lungs.  She required transport emergently to the hospital for treatment.

Definition:  A pulmonary embolism (PE) is a blockage of one of the blood vessels to the lungs.  These are usually caused by a blood clot that travels from somewhere else in the body, most commonly from the legs.  Other causes of blockages to the blood vessels in the lungs are air bubbles, or from tiny pieces of fat.

A pulmonary embolism is a serious condition that is a medical emergency.  A blocked artery or vein in the lung can make it hard to breath and can lead to damage to the lungs and can even cause death.

Most of the time the blood clots start in the legs, or in the pelvic area and then move along the veins and travel to the lungs.

Symptoms:  People who have blood clots in the lungs might complain of:

1)   Sharp, stabbing pain when they take a breath in

2)   Coughing up blood

3)   Rapid heart rate

4)   Trouble breathing or feeling short of breath

If you have any of these symptoms, it is important to call 9-1-1 and be evaluated in the hospital.  Do not try to drive yourself to the urgent care or to the hospital yourself.

Risk Factors:  There are some factors that can increase the chance of having a blood clot in your lungs including:

1)   Having a family history of blood clots or blood clotting disorders

2)   Having recent surgery – especially on the knees, lower legs or pelvis

3)   Smoking

4)   Taking birth control pills or estrogen replacement

5)   Having a previous history of DVT (Deep Venous Thrombosis) or PE

6)   Having a history of heart failure

7)   Patients with cancer

8)   History of kidney problems such as nephrotic syndrome

9)   Having a recent trauma or injury with a large clot (hematoma) – more likely to cause DVT if it’s in the legs

Diagnosis:  To diagnose a pulmonary embolism, special tests such as a special x-ray called a CT scan (Cat-Scan) with contrast.  During this test, the patient has special a detailed x-ray of the lungs while contrast (a solution of medication that can be seen under x-ray) is put into a vein (usually in the arm) and circulates through the lungs and rest of the body.  The CT scan is used to see the blood vessels and determine if a blood clot is present.  There are other tests to determine if a pulmonary embolism is present as well such as a ventilation/perfusion lung scan, but we usually use CT scan instead because it is easier and less time consuming.  If we suspect that there might be a blood clot in a patient’s leg, we can perform a vascular ultrasound to look for blood clots in the vessels of the legs.

Treatment:  We start treatment of a pulmonary embolism without delay to prevent a new blood clot from forming and to reduce the chance of enlargement of the existing clot.  Usually your own body’s enzymes dissolve the clot.  We treat patients by anticoagulation.  That means that we give medications to reduce the body’s abilities to form new blood clots – this is also sometimes called using “blood thinners.”  It isn’t actually thinning the blood however.  For patients who are at high risk for forming new blood clots, we sometimes put small screens or “filters” in a major blood vessel such as the inferior vena cava to prevent a new blood clot from reaching the lungs.

Most of the time we use a combination of oral anticoagulation medications such as Coumdin and also use an injectable medication such as heparin.  Patients who have pulmonary embolisms often stay in the hospital for a few days and receive intravenous heparin to prevent more blood clots from forming.  It takes a few days for the medication that is taken orally to become effective, so during this time the patient is giving the heparin either through an IV or the heparin is injected under the patients skin.

Patients who have had a PE usually take the Coumadin (also called Warfarin) for a minimum of three months.  Some doctors recommend that patients with a PE take Coumadin or something similar for the rest of their lives.  Other medications to prevent blood clots might be used if the patient is pregnant or cannot tolerate Coumadin.

Prevention:  Patients who are in the hospital and confined to the bed for extended periods of time are usually started on a prophylactic dose of heparin each day or special compression devices on their legs to prevent blood clots.  People who are on long air plane flights, car, bus or train rides should get up regularly and stretch their legs to help prevent the development of the blood clot in their legs (DVT).  Patients who have had recent surgery often use heparin injections even at home for a few days to help prevent the development of a blood clot in their leg.

If you or someone you know if having symptoms of a pulmonary embolism (PE), they should dial 9-1-1 and go to the hospital immediately.  They should not attempt to drive to the hospital or urgent care.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com