Mom brings in her 24 year old daughter and says that she is not sure what happens, but the daughter suddenly goes into convulsions and starts shaking and having a seizure. You attach the EKG machine for fun, then you capture the following over the next 10 seconds. Is this artifact and shaking or something very bad?

A 20 year old patient comes in to the ER complaining that he was playing soccer, and the ball hit him in his chest. He feels like "I got the wind knocked out of me" and is doing well otherwise. He has no medical history, vitals are stable. One of the brightest ER interns decides to get an EKG, and you see the following:

What is this?

I just turned 34 this year and thought I needed to establish care with a physician. Plus I really wanted to know my numbers. Everyone should know their credit score, their lipid panel, their fasting glucose, their blood pressure, their TSH, and their Vitamin D level. These figures will tell you all you need about your health and what you need to do.

I recommend to all my 30-something friends, go see your doctors and get your numbers! Don't wait for one of these silent killers to strike!

I just got my results back and here they are: (in parenthesis are the goals or normal values)

Total Cholesterol: 184 (<200)
HDL: 44 (males >40, females>50)
LDL: 129 (<160, optional <130)
Triglycerides: 51 (<150)
Chol/HDL Ratio: 4.2 (<5)

BP: 130/70 (<120/80)

BMI: 26.3 (18.5-24.9)

Fasting Glucose: 80 (60-99)

Vitamin D level: 23 (>30)

TSH: 1.74 (1-5)

My impression and plan:

Lipids:

As far as my lipid panel goes. I don't like it. Yes, it falls within guidelines and looks pretty decent. But I like to be more aggressive about cholesterol control. 

If a patient walked in with this lipid panel I would be all over them about lifestyle modification, diet modification, exercise, and I'd give them 3 months to try and make some improvement. If they can't they'd be on a statin. 

In my case, I don't have much wiggle room in terms of lifestyle modification. I weigh at or very close to my ideal body weight, I eat very healthy, I don't eat saturated fat, I exercise like a mad man at least 2-3 times per week, sometimes way more, and I don't smoke or drink. Hence, this is my lipid panel. This is my genetics. In my case, I will probably start a low dose statin and see what happens. Probably a Crestor 5 or a Lipitor 10.

My total cholesterol is 184. I don't like this number. If I were a patient of mine, I would double whatever statin dose I was on, or start one. The guidelines state that a total cholesterol under 200 is ok.... but do you really want to be the guy with the 196? No. Guidelines are good basic information, but we need to strive for better. The guidelines from the NCEP ATP III are slightly outdated and need to be updated anyways. I am not going to be the guy with the cholesterol of 180 and settle for "mediocre".

My HDL (Healthy Cholesterol)  is 44. Sure it's over 40. But,  we like it to be over 45. Crestor and Lipitor can raise your good cholesterol. There are only a few things that raise HDL; exercise, Niacin, and a few statins (Crestor and Lipitor). Otherwise, you're stuck. Since I already exercise, this is another reason to start a statin.

My (Lethal Cholesterol) LDL is 129. The guidelines technically say under 160 if you have minimal risk factors, and under 130 if you have a few risk factors. I don't have any risk factors (obesity, hypertension, smoking, diabetes, family history, age, male sex, etc). If anything, I am a male.... so that is a risk factor. LDL is the primary target of therapy. When treating patients, I like to see it under 100 or under 70 in very high risk patients (diabetics, or already have CAD). So, statins are great at lowering LDL. That's their job.

My Triglycerides were only 51. This is a number I am especially proud of. I have never seen TGs this low before. This usually represents excess sugar that you have floating around in your blood stream. Triglycerides are chains of 3 sugars bound together. People who eat excess carbohydrates will have high TGs. Since, I don't eat carbs (unless they come from fruits and vegetables), this number is very low. Normally, we tell people with high TGs to start taking fish oil or flaxseed oil (Omega 3s) to help bring this down. I have some flaxseed oil pills at home and pop some every once in a while, but not consistently. So maybe that helped a little. Salmon and tuna have the most omega 3 of most fish we can eat.

My Cholesterol to HDL ratio is 4.2. Pretty high. We like it to be under 5.... but 4.2 is too close for me. I like to see numbers like 2.0 or 2.5. Not 4.2!

Blood Pressure:

Mine was 130/70. Pretty good. I had just walked in and barely had a chance to sit down when she took it. I am sure it'd be lower if she waited a few minutes. Not worried about that number. The lower your blood pressure, the longer you live, regardless of anything else. And for every 20/10 that your blood pressure is above 115/75, your chance of having a stroke doubles.

Body Mass Index:

This tells us how much you should weigh in relationship to your height. I'm five foot eight inches and weigh 173 pounds. It is used for males and females. Normal is between 18-24.9. Women should be to the lower end of the scale around 19-22 while men can be a little higher around 23-24. Yes, according to my BMI, I am overweight. Overweight is 25-29.9. Over 30 is obese. And over 40 is extremely obese.

While my BMI is in the "overweight" category, I don't mind. BMI doesn't work for that well for more muscular individuals. If you played high school sports, or carry around a lot of muscle mass, you will be at the higher end of normal. I've been involved in sports and weight lifting my entire life, and I know I carry around a lot more muscle than the average joe. In order for me to get under 25, I would have to lose about 10 pounds and get to a weight of 163. That's not impossible. And I could probably do it. I will work on this and see what happens. But I don't have much wiggle room here. Losing a few pounds isn't going to change my lipid panel either. 

Glucose:

My fasting glucose is way under 100. I'm very happy. No one's fasting glucose should even be close to 100. If your fasting glucose is creeping up and getting into the 90s, you and your doctor need to have a talk about insulin resistance (type 2 diabetes). I hate when physicians ignore fasting glucose numbers that are "high normal" and aren't aggressive about this issue. If this was you, would you want to wait until you are a full fledged diabetic and can't see, can't feel, and are peeing out protein? Get aggressive about this! Especially, if type 2 diabetes runs in their family! The only way you can get type 2 diabetes is if you inherit it! Please start taking Metformin right away!

Vitamin D:

Vitamin D plays a crucial role in nearly every metabolic reaction in our body. It's actually a hormone, not a vitamin. We are finding out more an more about Vitamin D every day. If you want your number, ask your doctor for a 25OH Vitamin D (25 Hydroxy Vitamin D). Not the other two. None of the others matter or are even useful. Vitamin D is important for our bone health, cardiovascular health, helps suppress inflammation, prevents myalgias, joint pain, stiffness, and nearly everything else.

My number was 23. This is low. Normal is considered 30 and up. But you start seeing problems in humans with vitamin D levels less than 40. So we ideally aim for a level of 50-70. So mine is pretty low. Under 10 is considered Vitamin D deficiency, and 10-30 is considered insufficiency. 

If you live north of Atlanta, cover all your skin with clothes (most Muslim women), wear sunblock or have darker skin.... you are deficient. Get it checked and get treated. Our body uses sunlight to convert Vitamin D to it's active form. So yes, I started taking Vitamin D supplements.

TSH:

This tells us about your thyroid function. Mine is 1.74. Perfect! When we treat people with thyroid issues, we like to see their TSH be between 1 and 2. So this is perfect!

Any thoughts?

I would like to hear all of your thoughts and analysis. Would you be as aggressive? In a 34 year old, otherwise healthy, compliant male? Would you start a statin?  Try anything else?

No, you do not need to exercise to lose weight. It's true. You can lose almost all the weight you want just by changing your eating habits. The vast majority of people can get to with 10-15% of their desired weight with diet alone.

Too often physicians tell patients, "Diet AND exercise." We hear this all the time. Diet AND exercise. The fact of the matter is, that diet alone is usually enough to achieve very significant weight loss.

Most Americans find excuses to not have time to exercise. Work, kids, time, money, motivation, running late, etc. Exercise is usually our last priority. This is unfortunate, but true.

When doctors tell patients that weight loss requires diet AND exercise. We have already built excuses into the system. They can't find time to exercise, hence, they will not be able to lose weight. We are giving people a reason to not lose weight.

We should rephrase our recommendations. You need to DIET ONLY. Forget exercise! If you have time, please exercise, it's great for your heart. But it is not necessary for weight loss. But weight loss is necessary! Please lose weight.

We have to be clear and truthful. Diet modification is more than enough to cause major weight loss. Let's not tie it to exercise and destin both to noncompliance. They won't do either.

How useful is exercise?

Assuming you weigh 200 pounds, if you walk or jog for 3 miles you will burn about 300 calories. That's not much! That's one plain bagel from Panera. 

Exercise should not be used as a way to burn calories. It should be used to increase your heart rate and improve your cardiovascular health. But's it's not a good way to burn calories.

A 200 pound person doing squats for 2 minutes straight burns 320 calories. That's only 2 minutes of resistance training! Even if you aren't putting up any weight, just your body weight. Two minutes, 320 calories. Better to do two minutes of squats than run for 3 miles if you just want to burn calories.

Back to our problem, diet does not have to be tied to exercise. You can get to within 10-15% of your target weight with diet alone. If your ideal body weight is supposed to be 150 pounds, you can easily get to 165 with just diet. If you want to weigh 170, you can easily get to 187 with JUST DIET!

Start dieting and lose weight! NO EXCUSES! I don't want to hear about not being able to get to the gym, no time to run, had to pick up the kids, can't afford a gym membership.... etc, etc.

Dieting is free! (and may cost you less than what you are paying now) You will be paying a lot less for food, since you will be eating a lot less food. You don't have time to exercise, but you definitely have time to diet. You eat every day, right? Just eat way less. It's not rocket science.

There are all kinds of diets available to use. What it comes down to is picking one and sticking to it. They all work! Just pick a diet and do it.

Diets should not be temporary. You breathe every day for the rest of your life. You should diet every day for the rest of your life! All "diet" means is what we eat and consume. Start eating way less, and way healthier. We all know what that means. It's not complicated. Eat less, eat better. We don't need a PhD to understand that.

Here are some places to start:

http://www.mypyramid.gov

http://www.nutrition.gov

Every once in a while you wonder if people actually understand what they are dealing with and whether or not they really understand what's going on. A recent encounter with another physician perplexed me.

A patient is brought to the ER because he or she is found unconscious by a family member. It turns out the EKG looks "scary" and they call cardiology. What the ER thought they saw on the EKG was an entity called "ST Elevations" which typically means someone is having an acute heart attack and needs to go to the cath lab to get the artery opened up.

We arrive. It turns out the patient is in acute renal failure, with a creatinine of 3.5, the potassium is over 8 (which gives you a similarly bizarre EKG pattern), and has a blood sugar of over 1300, and a bicarbonate of 5. The ER also ordered a troponin which was indeterminant and a BNP which was 1300.

The patient on paper looks like he is in Diabetic Ketoacidosis, dehydrated as hell, and has gone into acute renal failure from the severe dehydration. Yes, the elevated potassium is very high and at such high levels you get EKG changes which look very abnormal. A potassium over 7.5 gives you wide QRS complexes, wide T waves (the QRSs and Ts look similar), lack of P waves (or very blunted), bradycardia. 

We rehydrate the patient, his potassium quickly comes down (as is expected, because they are really potassium deficient), treat his DKA, and over the next few days his kidneys resume normal function.

A few days later one of the physicians from the ER saw me in the hallway and asked me, "Hey, how do you explain the CHF in that guy?"

I asked, "CHF? Why do you think he was congested? You think he is volume overloaded?"

"His BNP was like 1300"

"He was in acute renal failure."

"So, why was he volume overloaded?"

"He wasn't. He was about as dry as they come. You coulda given him 10 Liters and he'd be fine."

"And the BNP?"

"You can't really evaluate a BNP with renal failure. Nor troponin for that matter. Just toss those two out the window."

Sometimes you just think to yourself, "Wow!" Sometimes things that you think are common knowledge may not always be. We can't rely on merely tests and numbers. We can't be robots. We have to understand what happens behind the numbers.

Medicine humbles you every day! There isn't a day that goes by that I don't learn something new.

Eating cholesterol does not raise your cholesterol! People need to stop worrying about eating cholesterol! Eat all the eggs and shrimp you want!

What raises your cholesterol is saturated fats! These are fats that are SOLID at room temperature. Butter, margarine, cheese, fat on steak, bacon, chicken skin, pork, goose fat, cream, ice cream, and the fat in milk (even though it looks like liquid, it's actually solid fat particles floating around in liquid).

Eighty-five to ninety percent of your total cholesterol comes from your liver. Our liver makes over 85% of our cholesterol! Only a small percentage comes from food you eat. If you don't eat cholesterol, your liver makes more to make up for the difference. If you eat cholesterol, your liver will make less. So it doesn't matter how much you eat!

What tells your liver to make cholesterol?

SATURATED FAT!

Fats that are solid at room temperature. Avoid those and you will be ok! If you remember that, you will be fine.

We always tell our patients to first try diet and exercise to help improve their cholesterol numbers. So they go around and stop buying foods that say "cholesterol" on the label, or buy "cholesterol free" foods. Bad idea! You liver will just make up the difference.

What we should tell them to do is to avoid foods that have saturated fat in them. Solid at room temperature! Remember that!

Saturated fats are found in high amounts in:

Butter, Coconut, all those butter substitutes, Cheese, Pork, Beef, Chicken skin, Goose fat, veal, sausage, hot dogs, bacon, processed meats, cream, milk and other dairy products, ice cream, etc. You get the picture. SOLID FATS! When you look at that steak and see the marbelling and fat in between the muscle fibers, or the fat on ribs and lamb chops....  IT's SOLID FAT!!!!!

Avoid Solid Fat!

But, there are two liquid fats that contain a lot of saturated fat; coconut oil and palm oil. But my guess is no one really eats those. Especially, not here in the United States. Butter, cheese, cream, bacon, pork, and beef are our main problem.

What about trans fats?

These are liquid fats (like vegetable oil) that are heated in the presence of hydrogen to make them semi-solid. Like all those butter substitutes. These are awful!

Trans fats are even worse for cholesterol levels than saturated fat and cholesterol itself because they raise LDL ("bad") cholesterol AND lower HDL ("good") cholesterol.

February is Women's Heart Disease Awareness Month! In honor of women's heart health, I will dedicate a majority of my posts in February to Women's Cardiovascular Health Issues.

I plan on covering several topics: (possibly more)

1. General Cardiovascular Health
2. Tobacco Cessation
3. Why it's harder for women to lose weight, and how to break through
4. What really raises your cholesterol? (it's not the cholesterol you eat)
5. The Alo Diet (hey, if Atkins can have one, so can I)
6. How to look young for a long time

For starters, did you know:

Cardiovascular disease kills approximately 450,000 women each year, about one every minute.

While 1 in 40 American women die of breast cancer, about 1 in 3 die from cardiovascular disease.

More women die of cardiovascular disease than the next five causes of death combined, including all forms of cancer.

Ninety percent of women have one or more risk factors for developing heart disease.

Only 1 in 5 women believe that heart disease is her greatest health threat.

Heart disease is largely preventable.

In fact, 80 percent of cardiac events in women may be prevented if women make the right choices for their hearts, involving diet, exercise and abstinence from smoking.

Cigarette smoking contributes adversely to the top 5 killers of women.

Lear more at http://www.goredforwomen.org/

Try to wear something BRIGHT RED throughout February to raise awareness of the number one killer of women!

If the ladies can do it....

Then men can too....

A while back we were discharging a patient from the hospital and gave her prescriptions for all of her medications. One of her prescriptions was for Crestor (the most powerful cholesterol lowering medication). The nurse calls me and says that the patient would like to ask me a few questions before she leaves.

"Doctor, I'm allergic to Crestor. Can I take something else."

"Maam, how do you know you are allergic?"

"I break out in hives and get itchy when I take it."

"Well, you've been on Crestor for the past two weeks while here in the hospital."

"Oh really?"

"Yes."

"Well, maybe that's why I haven't been able to sleep. Can I have a different medication?"

"Like what?"

"Vicodin?"

I look at her puzzled and ask, "How will that fix your cholesterol?"

"I don't know. Isn't that for cholesterol?"

"No, it's a pain reliever."

"Well, if I'm not in pain, won't my cholesterol get better?"

"No, maam. I'll give you a prescription for something else."

Any other funny patient stories, post them below!

Back in May of 2008, the American Heart Association changed the CPR and resuscitation protocols. You no longer have to do mouth-to-mouth CPR and if it is an in-hospital arrest, you don't have to intubate right away.

They have done research and have found that doing proper chest compressions, in and of itself, provides plenty of air exchange. The air exchange is not the problem, the problem is circulation. They need blood to circulate the oxygen, so you have to do compressions. 

They also found that if you keep telling people to do mouth to mouth, they are less likely to help out. They just walk away quickly. That doesn't help anyone.

If you find someone down and without a pulse, start chest compressions. It's that simple! Nothing saves lives or prolongs lives more than chest compressions. Deep, fast chest compressions. 100 per minute. When a chest is compressed and allowed to recoil, that draws plenty of air and oxygen into the lungs. Further, stopping chest compressions to breathe into their mouths, is an interruption of blood flow to the brain. The brain does not tolerate those kinds of interruptions very well. You need circulation!

In normal humans, (who are alive and walking around) tissues and organs extract only 25% of total oxygen from blood. When someone isn't breathing, tissues and organs can extract more oxygen. Doing chest compressions, provides more than enough air and oxygen for tissues and organs to work with.

Being someone that lives in the hospital, I see it all the time. Whenever there is a cardiac arrest, everyone jumps up and down and gets excited about "airway". Everyone wants to be a hero and be the one to intubate. In reality, you can wait. Intubation is the last step. If they don't have a pulse, start compressions. You can always just "bag" the patient with the mask until later when you figure out what is going on. And that is what the American Heart Association recommends. Wait on airway!

Airways are not benign. Lots of bad things can happen when you are trying to get an airway. Just bag them until things are more stable. 

Unfortunately, old habits are hard to break. Physicians and other health professionals are always taught the "ABCs" of cardiac arrest:

Airway
Breathing
Circulation

I am not sure why airway and breathing are before circulation. Circulation should come first! They should just throw out A and B. Or put them waaaaaaaaaaay last! It should be C...... AB or C....... BA. But I guess it's easier to remember if you just teach everyone "ABC". Doctors are supposed to be smart and not need to rely on such sophomoric mnemonics to help them practice good care.

Next time you run to a code blue, you can sound smart by stating that, "We can wait on airway, that was taken out of the guidelines two years ago."

Wait till the patient has been stabilized, or you know what is really going. You can hold off on airway until you get to the ICU or a more controlled environment and wait until you know that nothing else will suffice and you have to have an airway. If you are in the mall, just do chest compressions until the paramedics arrive. You will have saved a life!

Smoking Hookah (aka nargileh, argeelah, narjile, goza, water pipe, sheesha) has become fashionable among educated professionals and college kids in the United States. Smoking has always been a disease of the poor and uneducated, however, Hookah seems to be transcending these bounds. For some reason, hookah smoking has been able to make it out of the ghettos of uneducated Arabia, Turkey, and Egypt and make it to America's university campii. Why are educated, intelligent young people taking up this habit? Is it peer pressure, mental illness, or just a fad?

It's been estimated that 43% of cigarettes in the US are consumed by people with mental illness. Experts feel that smoking leads to depression, and depression leads to smoking. So are these kids using Hookah to help their mental illness?

A study on young people in the United Arab Emirates found that 69% of hookah smokers had a college education, while 23% had a high school education. Are they just ignoring the facts? Or do they not care? Do they have mental health disease?

Further, the myth about smokers losing weight  has been demystified. A recent study has shown that teenagers that smoke are more likely to be obese adults. Probably because if they are making bad choices as teens, they will likely make bad choices as adults. Further, they have an oral addiction. They constantly need to be putting things in their mouth.

Is Hookah better than cigarettes?
In two words: Hell No! In one study it was found that smoking Hookah for one hour is equivalent to smoking 200 (and up to 400) cigarettes. What if you are just around but don't smoke? Even if you never touch the Hookah, if you are in the room for one hour, you have smoked nearly 100 (and up to 200) cigarettes. Another study found that one puff on a cigarette gives the user 50mL of smoke volume, whereas one inhalation on a Hookah pipe gives the user 500mL of smoke. Ten times more! And that's on just one inhalation! It's estimated that in a 30 minute Hookah session most adults consume approximately 50 Liters of smoke volume! Nearly 1000 times more! That is unbelievable!

Cancer shmanser!
We all know that smoke, tar, and the carcinogens in smoke cause all kinds of cancers. That is obvious. We don't need to repeat those over and over. Bladder cancer, lung cancer, esophageal cancer, oral cancer, tongue cancer, and nearly every other cancer! Not to mention it destroys your blood vessels from the inside out, which in turn destroys every organ system! Every single patient I have had that had a heart attack before the age of 50, has been a smoker. Some as young as 26 and 32. Awful!

Other effects?
Young people don't care if you tell them they will get cancer or a heart attack when they are old and die. What they care about is immediate results. Smoking causes yellow teeth, yellow, brittle hair, bad breath, wrinkles in your skin (especially on your face), bad hands and fingers (the tips of your fingers get fatter and shorter), vocal changes, tooth and gum disease, and a lot of things that are easily noticeable. Nasty! You can easily tell who is a smoker and who isn't by how they look.

Is Hookah Haram?
The word Haram in Arabic and Islamic tradition means "religiously forbidden." As Muslims, one of our most important tennets is "No harm and no harming". This is very similar to the physician's creed: "First do no harm!"

The Prophet Muhammad (and all religious leaders) have taught that people should not harm themselves. The Prophet Muhammad said: "No Harm and No Harming!"

Jesus and the Bible teach in Corinthians: "Do you not know that your body is a temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore honor God with your body," (1 Cor. 6:19-20).

In other words, DO NOT HARM YOURSELVES NOR YOUR BODIES!

Professional athletes are supposed to take care of their bodies and be ready to play and do very well. Surveys of former NFL players have shown a very low smoking rate compared to the national average. That should tell you enough!

I am no religious scholar by any means, but to me it's pretty clear: Hookah is Haram (and Horrible)!

If you need resources and links to articles:

We all know that nicotine is not the worse part of cigarettes. That's just the part that keeps you addicted. By far, smoking is the hardest addiction to break, in part due to ncotine and it's physically addicting properties. They want you addicted, and put it in their. The other part of smoke is the carcinogenic, wrinkle-ogenic, and nasty-ogenic parts.

Further, hookah does contain tar, nicotine, and carbon and much more than cigarettes:
http://www.kansan.com/photos/2009/oct/08/6925/

The numbers on smoke volume come from "The Hookah Lounge":
http://www.thehookahlounge.org/2006/06/30/is-smoking-a-hookah-bad-for-your-health/

Which is actually a website that actually advocates the use of hookah as well as others who have connected hookah to machines and measured smoke volume. Those numbers are from a World Health Organization study. You can view the WHO advisory here:

http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf

Which is where most of the research comes from.

The Mayo Clinic also has a resource on Hookah:
http://www.mayoclinic.com/health/hookah/AN01265

and demonstrates hookah to cigarette equivalency.

An article here also shows that hookah smoke is just as bad, if not worse based on a JAMA article:
http://health.usnews.com/usnews/health/healthday/080103/hookah-smoking-as-tough-on-lungs-as-cigarettes.htm

and here:
http://www.reuters.com/article/lifestyleMolt/idUSTRE57O2RZ20090825

and:
http://www.washingtonpost.com/wp-dyn/content/article/2006/07/03/AR2006070300774.html