Medical Examiner 3-1-24

THEDEADLIEST

Nobody smokes anymore, right?

It would be nice if that was true. Unfortunately, worldwide there are more smokers today than there were in the early 1990s. Surprised?

Scientific American reported in September 2023 that even though the percentage of people who smoke globally has dropped from 27.8% in 1990 to 19.6% in 2019, due to population growth the actual number of smokers has increased during the same period, from about a billion people in 1990 to 1.14 billion in 2019.

Smoking is Enemy #1 in the world of healthcare. All by itself, smoking is responsible for 13.6% of all deaths across the globe. CDC statistics say smoking kills more people in the U.S. each year than car crashes, alcohol, drug overdoses, and HIV combined. It is the runaway leader among our deadliest drugs, the top three of which, ironically enough — tobacco, alcohol, and opioid painkillers — are legal. To illustrate how deadly tobacco is, if you added up all the time lost compared to normal life expectancies by those who died as a result of smoking, the loss in 2019 alone was 200 million years, says a study published in Lancet. Those numbers pale in comparison to future projections. The 100 million people who died from tobacco-related causes in the 20th century is expected to grow to 1 billion during the 21st century.

Tobacco’s deadly effects are manifest in four main ways: heart disease, chronic obstructive pulmonary disease (COPD), stroke, and cancers of the trachea, bronchi, and lungs.

And that’s just the tip of tobacco’s unsalubrious iceberg. But what would you expect when cigarette smoke contains more than 7,000 chemicals, including dozens of carcinogens like arsenic?

The thing is, nicotine creates havoc in ways many people would never expect. Smoking is bad for skin. It contributes to premature aging. It elevates the risk of tuberculosis, rheumatoid arthritis, and certain eye diseases. It can cause impotence. And according to CDC statistics, people who smoke are 30-40% more likely to get type 2 diabetes than people who don’t smoke. Who knew, right? But again, a cocktail of more than 7,000 foreign substances in places they’re not supposed to be has to wreak damage of some kind, and it turns out to be many kinds.

Before proceeding any farther, a word of apology: surely very

few people fit into two competing demographics: people who smoke and read the Medical Examiner. That has to be a rare breed. At least we hope it is.

So then, why is this our front page story?

Many reasons. Maybe there are one or two of our readers out there who still smoke. Surveys show the vast majority of smokers want to quit. And many who have quit are in a constant battle to stay quit. Plus many of us have loved ones, friends, co-workers and others in our lives who still smoke.

How can smokers be encouraged to quit?

It’s a challenge that some have said is more difficult than quitting heroin. But it is definitely doable: as of 2002 there are more ex-smokers than current smokers.

Quite a few methods have been devised to help pry smokers away from their hardearned money, but the only FDA-approved methods are NRTs (nicotine replacement therapies), smoking cessation medicines, and counseling. Notice that e-cigarettes did not make the approved list. Long-term data on their health effects are unknown, versus decades of well-documented results from taking the FDA-approved route.

If you’re one of those many smokers who want to quit, don’t go it alone. Talk to your doctor and get help to succeed. Quitting by age 40 cancels 90% of smoking’s risk, but quitting at any age greatly reduces the risk of a tobacco-related death.

Quitting might not be easy, but it’s well worth the effort. +

PARENTHOOD

by Dr. Warren Umansky, PhD

Your 12-year-old son has never had many friends. At family gatherings, he prefers to go off on his own. He is a very picky eater and gets overwhelmed in loud and busy settings. In kindergarten, he sometimes crawled under his desk or would try to leave the room when he became frustrated. When he was in elementary school, his teachers expressed concerns that he would always walk around the playground alone during recess. When he comes home now, he goes right to his room and stays there playing on his phone until it is time for dinner. What should you do?

A. Contact his pediatrician and request a referral to a behavioral health provider.

B. He seems happy and all kids are different. Just adapt to his wants and needs.

C. Tell him that you are taking everything that he likes away from him until his behavior becomes more like the behaviors of your friends’ children.

D. Talk to him regularly and try to get an understanding of the world from his perspective.

If you answered:

A. There have been many red flags along the way that you might or might not have addressed. They need to be addressed now. A behavioral health specialist (psychiatrist, psychologist or counselor) is trained to work with you and your child.

B. Continuing to watch and wait is not a good approach for a 12-year-old. His happiness comes from being left alone. This may not be the key to future happiness and success.

C. By the age of 12, you might have tried this approach already and should know if he can change behavior to be more “normal.” It is not a winning approach at this time.

D. You should be talking to your children all the time. At age 12 is not the time to begin. Family mealtime is a good vehicle to slow down the daily rush and get everyone talking to each other.

We want to address concerns when they first appear by talking with professionals who are best trained to help answer your questions. Be careful about getting help on the internet. The information is not always accurate or safe. Dr. Umansky has a child behavioral health practice in Augusta.

MEDICAL MYTHOLOGY

SOME MYTHS ARE HEART-BREAKING

Literally.

And yes, we know Heart Month was in February and this issue is dated March 1. But really, shouldn’t every month be a month when heart health is promoted?

The answer: yes.

The irony connected with heart disease arises from how common it is, yet how little most of us know about it.

Buckle your seatbelt before reading the next paragraph.

Every year nearly 700,000 Americans die of heart disease. That’s 1 in every 5 deaths, and averages out to a fatality roughly every 30 seconds. Every year more than 800,000 people in the United States have a heart attack. Coronary heart disease alone kills more than 375,000 Americans a year. So we are all on red alert to know the signs and symptoms, right?

Sadly, no. Most of us are not aware of the symptoms, or if we are at higher than average risk.

As one example, every one of us has heard heart disease described as a “silent killer.”

In other words, things can be happening that are so serious that they can become life-threatening, yet there will be virtually no symptoms.

Or, to be slightly more spe-

cific, heart disease does generate symptoms, the very first of which might be a heart attack. Possibly even a fatal heart attack. As the first symptom!

One of the key barometers of heart health is blood pressure. It can be sky-high without giving its host the courtesy of a single clue that it is doing its insidious damage.

Ditto for high cholesterol. There are no symptoms until there are, and by then they can be very serious.

All of this underscores the need for routine checkups, even for the person who feels as fit as a fiddle and as strong as an ox. Get a second opinion on that. The only thing better than a perfectly clean bill of health is a checkup that finds a serious matter that can be treated and stopped in its tracks before causing something terrible.

Another heart-breaking myth is that heart disease is mainly a guy thing. Women are somehow immune. It would be nice if that was true, but the unfortunate fact is that the most common cause of death among women is heart disease.

Sad to say, some people in the business of medicine have even bought into the myth. One cardiologist observed that

“when women do have heart attacks, they are more likely to suffer a bad outcome than men, in part because either they themselves or their medical team might not take their symptoms seriously.”

On a related note, the actual symptoms of a heart attack are the subject of a fair amount of mythology, and they can be different for women, leading to...well, see previous paragraph.

The CDC says that many women having a heart attack experience feelings of nausea, light-headedness, or fatigue.

Nowhere in the preceding paragraph can the words “chest pain” be found. Many believe that chest pains are the classic symptom of a heart attack. So their absence means “this isn’t a heart attack.”

Here at our sprawling Medical Examiner World Headquarters campus in Augusta, we know of a case where an emergency medical services supervisor, a veteran first responder, told his fellow workers one day that he was having bad indigestion and was going to go home for the day. He failed to arrive for work the next morning and was found dead in bed; the autopsy results confirmed the cause as a heart attack.

One person might say he should have known better, but someone else might say if even a trained professional like him can fail to recognize the symptoms, it’s a wakeup call for everyone to learn the danger signals of heart disease.

His sad experience and several hundred thousand others each year underscore an important fact: many if not most cases of heart disease are preventable.

Know the myths. Know the facts. And get a checkup. + +

If so, we want to tell you two things:

1) Happy early birthday!

2) This is the year to take the next step in protecting your future and the future of your family.

You guessed it. This is the year you are eligible for Medicare. And we can be right by your side as you navigate the process. If you have any questions or just want to talk through your specific situation, we are just an email or phone call away.

Your great aunt Nellie keeps her thermostat at 78° and sits next to a portable space heater and she still thinks the house is too cold.

As many people who have been around the sun a few times know, older people often feel cold or may have a hard time warming up. What’s up with that, as the kids say.

It’s not imaginary. In fact, it’s a natural part of aging. Our skin starts to thin as we age, and part of that process is the loss of fat cells layered just beneath the skin. Doctors liken that fat padding to home insulation. A thicker layer will keep in more heat; a thinner layer allows more heat to escape.

Another natural result of aging is gradual loss of mucle. It starts as early as age 30, say the experts, and progresses a handful of percentage points each decade. By age 65, the average loss of muscle mass can be 10% or more. By 80, the loss can be 30%.

Aside from the obvious loss of strength, muscle movement of any kind at any age burns fuel and therefore generates heat. When the only goal of muscular activity is movement, the heat byproduct is wasted energy, but when we’re cold we can use activity to warm us up. The best illustration of that is the body’s natural reaction to extreme cold: shivering. This automatic response uses muscle movement to generate heat. We can also generate our own heat when cold by doing some household chores, exercises, or going for a walk.

Additionally, our metabolism — the calories we burn when at rest — usually slows down to some degree as we age. Translation: less internal heat generation. And circulation decreases too, as blood vessels become less flexible and the whole circulatory system is a bit less efficient with each passing year. The result: cold hands, cold feet, cold everything.

It’s not a bad idea to tell your doctor if you feel cold all the time. It’s probably nothing, but it could be a medical condition that needs to be treated, or a reaction to medications. Maybe a different drug can be prescribed.

One of the best solutions is right around the corner: hot weather is not far off. In the meantime, quilts, warm sweaters and thick socks can keep us warm and cozy. +

Who is this?

When you’re torn between a career in music and medicine and one of your best friends is Johannes Brahms, you’re probably not going into medicine.

Note: we said probably

Then again, if your mother is constantly nagging you to go into medicine, you’ve got to consider that, which is exactly what this man, Theodor Billroth (1829-1894), did. And the rest is in the pages of the medical history books.

Not exactly.

He did enroll in Germany’s University of Greifswald to study medicine, but spent his entire first term studying music and practicing the piano. Even so, for some reason he caught the eye of professor of surgery Wilhelm Baum, a man whose resume is littered with both mentors and students who are noteworthy figures in medicine. Baum was about to embark on a trip to the University of Göttingen, and he invited Billroth along. His fate was sealed. In fact, when Professor Baum accepted a professorship at Göttingen, Billroth entered the transfer portal, as we say these days, and went there with his mentor. He completed his medical doctorate in 1852, and now the rest is in the medical history books.

Well, Dr. Billroth’s medical career actually began in less than spectacular fashion. He had accepted an offer from the University of Zurich to be its Chair of Clinical Surgery, a position that was both clinical and academic. During his first semester of teaching he had a mere ten students, and he told a friend that the income he generated from his practice wouldn’t even buy his morning cup of coffee.

Thanks to his infectious personality, always a plus in the medical profession, his reputation grew and students and colleagues alike flocked to his lectures. Within a few years, the stature of both Billroth and the University of Zurich took off. One of his innovations was audits, which published all surgical outcomes, good and bad, as a means of improving medical techniques and patient care.

Billroth accepted a position at the University of Vienna in 1867, where his excellence as a surgeon truly came to the fore. As a result of the Franco-Prussian War, he got plenty of practice in abdominal surgery. He is, in fact, known to this day as the father of modern abdominal surgery, part of which was administrative in nature: he advocated prolonged surgical apprenticeships involving intensive training and education.

In the operating theater, however, he was the first to perform an esophagectomy, removing a diseased section of the esophagus and reconnecting the remaining ends; he was the first surgeon to completely remove a cancerous larynx; he invented and performed the first successful gastrectomy to excise cancerous portions of the stomach, a procedure known as Billroth I, which has gradually evolved to today’s Billroth II.

Ever the musician, his death cut short research he was conducting into the cognitive skills required for the perception of music. +

THE VAPE LANDSCAPE

Nearly half of youth who ever tried vapes are still using them according to the 2023 National Youth Tobacco Survey, and over a quarter of these young people use them daily.1 The alarming figures in this report suggest that many youth are dependent on nicotine, the highly addictive chemical in vapes, cigarettes, and other tobacco products.

Any nicotine use is unsafe for youth, but you can help. Learning about the dangers of vaping and why young people are more at risk can prepare you to have the “vape talk” with your children. Having the conversation now could benefit them for a lifetime.

Nicotine-the brain disruptor

JUUL, the brand that started the youth vaping epidemic, estimates that their original vapes have as much nicotine as 20 cigarettes.2 Newer JUUL models and many commonly used brands have that much nicotine or more.3 Young people are more at risk for trying vapes and becoming addicted to them because nicotine takes advantage of the normal brain development that happens during adolescence. Nicotine also disrupts this brain development which can result in long-term consequences for youth who vape

From ages 10 to about 25, the brain goes through a critical and amazing period where pathways between brain cells are made quickly and then strengthened, creating the type of brain young people will take with them into adulthood. The young brain prepares for this new phase of life by focusing its energy on gaining experience by trying new behaviors.4 The brain uses dopamine, the “feel good” hormone that trains the brain to repeat behaviors, to encourage the risk taking required to try new things.4-5 This feedback loop of dopamine and fast learning is beneficial to young people when they are trying out a new sport, musical instrument, or technology, but it makes them vulnerable to dangerous behaviors like vaping as well.

The reward system in our brain was not made for nicotine or other drugs, but nicotine hijacks this system and rewards the brain with dopamine which encourages young people to continue vaping. Repeating the behavior strengthens these brain pathways, resulting in addiction.4-5 The addiction pathways nicotine builds increase the chances that young people will continue to vape; 6 put them at greater risk to start using

cigarettes (the number one cause of preventable death in the U.S.); 6-9 and even increase the likelihood they will develop an addiction to other drugs.10-11 Nicotine also disrupts other brain pathways that are developing during this time related to attention, memory, impulse control, and mood management.12 These disruptions can make it difficult to focus in class, study for tests, and build healthy relationships with peers. Some young people will outgrow their vaping habit, but research suggests that nicotine exposure during adolescence can cause some of these changes to be permanent.13 Addiction to nicotine also results in exposure to other dangerous chemicals in vapes. Cancer-causing chemicals like formaldehyde, heavy metals like nickel and tin, and unidentified chemicals with unknown harms have also been found in vapes and affect other organs besides the brain.14-15

How you can help

2023 marks the 10th year in a row that vapes are the most used tobacco product among youth, but you can help end that trend. Educating yourself and talking to your children about the consequences of vaping can help them make informed decisions about their health. For information on how to start the conversation, check out these resources from Parents Against Vaping e-cigarettesAsk the Expert webinar; The American Lung Association- Conversation Guide; U.S. Surgeon General- Tip Sheet; and Campaign for Tobacco Free Kids- Tip Sheet. If you know a young person who vapes and want to support their quit journey, evidence-based resources are available for them at This is Quitting, Smokefree Teen, and Not on Tobacco. For more information or resources on youth vaping, including presentations for youth and adults, please reach out to us. Nyree and I are on your team! #TeamEndtheTrend #TeamVapeTalk

“The C Word” is a news brief of the Georgia Cancer Center at Augusta University. For cancer information visit: augusta.edu/cancer/community.To request presentations or exhibits, contact Maryclaire Regan at mregan@augusta. edu|706-721-4539 or Nyree Riley at nriley@augusta.edu|706-721-8353. Virtual presentations can also be arranged.

Editor’s note: References are listed on page 5

Middle Age

BY J.B. COLLUM

Some people say that as we age we have to get used to the fact that we just can’t do the things we used to. I say that we still can do pretty much anything we want, as long as we don’t mind it taking longer and we don’t mind how we look when we’re doing it. It isn’t always that we can’t do something. We might just decide it isn’t worth the trouble, or maybe we don’t like doing that thing anymore. That’s my story and I’m sticking to it. I’ll provide some examples.

My wife and I could still take trips to Disney World if we wanted to. That said, it just isn’t as fun or appealing as it used to be for several reasons, some of which have to do with our age. The rest of the reasons have to do with the cost. As far as age being a factor, I’ll give you a list of the age factors that have kept us away for nearly a dozen years:

• We’re saving for retirement since it is not far away. We’re not saving very well, but we’re trying to do better.

• The older I get, the less I like crowds.

• The older I get, the less I seem to be able to tolerate high heat and humidity.

• The older I get, the less I can tolerate stupidity and rude behavior that both seem to be ubiquitous these days.

• The last time I rode a roller coaster might be the last time I ever ride a roller coaster: I was nauseated for an hour and in pain for a week.

• They removed a lot of the nostalgic old attractions that I remember from my youth and half the reason I went was for the nostalgia.

After reading that list, I feel like I need to add this: “Get off my lawn!” Not really, but I feel more and more like my grumpy old Uncle Charlie as I reflect on this, so I’d better watch it before turn into the guy who tells his little great nephews (including me) to “keep their hands off my stuff!” That still gives me the shivers. I know my brother Jeremy probably feels that too, especially since he was younger.

Just this week, we decided to take a long weekend to visit our son in Myrtle Beach and life stepped in to make it more difficult. I got off work early so that we could leave around 4 pm, but when I got home I discovered my wife by the front door nursing a hurt ankle. She had been putting some of her things in the car for our trip and fell coming up the steps and twisted her ankle. It was already swollen, so I told her she needed to let me take her to urgent care. I said maybe we should postpone the trip to another weekend, but she was having none of that. Instead, she had me and our daughter pack the car and then she had us help her down the steps and into the vehicle. Fortunately, it is a large SUV, so it wasn’t that difficult to get her in there since we didn’t have to bend over. Bending over is another thing that gets difficult with age.

On our drive to Myrtle Beach, we tried various places that we expected or hoped would have the correct kind of brace or support she needed for her ankle to make it easier to walk. I had loaned her one of my canes, although she hasn’t shown much aptitude for using it so far despite my best coaching efforts. That’s probably my fault though. We finally found what she needed at the fourth place we checked, and that was actually only about a mile from our destination. The problem was that, even with the brace, she couldn’t get up the steps of our son’s condo. I offered to let her ride me up the steps piggyback, but she refused my chivalrous offer much to my husbandly disappointment and my back’s great delight. My chivalry and aching body parts often spar. As long as the former wins most of the battles, I can live with it I suppose.

Our daughter had booked a nice condo just a short distance away, and since it had an elevator it was decided that we would stay there instead of with our son for this trip. She had plenty of room anyway so we made that call though it was already about 10 pm and we were pretty tired.

We made our way there, but Lorie’s ankle was so bad off by then that we asked the resort for a wheelchair. They loaned us a beach style one with fat inflated tires that doesn’t even have wheels that can turn left or right This time my chivalrous side would not cede the battle to my tired body. At each turn, I essentially had to either lift the back to point the wheelchair in the right direction or try to lean her back to move the front wheels in the new direction. The wheelchair proved equally stalwart in its defense against either of these two methods, so I settled on a tactic that hurt the least, which ended up being me just dragging the back wheels into line at each and every turn. Of course, to get to our room required about as many turns as a walk through the Dole Pineapple maze in Hawaii (look it up), so by the time we got to the room, I was sweating buckets despite the temperature being below 50 outside and most of the way to the room being open to the elements, including the cold wind.

But we did finally get to the room. You might think our ordeal was over after finally getting settled in, wouldn’t you? Well, you’d be wrong. Tune in next issue where you’ll hear about what woke me up at 2:30 in the morning and how I had to deal with it so that any of us could get some sleep. Oh, and don’t miss the disaster that caused us to have to move rooms only a few short hours later.

J.B. Collum is a local novelist, humorist and columnist who wants to be Mark Twain when he grows up. He may be reached at johnbcollum@gmail.com

REFERENCES from page 4

1. Birdsey, J., Cornelius, M., Jamal, A., et al. (2023). Tobacco Product Use Among U.S. Middle and High School Students- National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep 2023;72:1173-1182. http://dx.doi.org/10.15585/mmwr.mm7244a1

2. Truth Initiative. (2019, February 26). How much nicotine is in JUUL? Truth Initiative. https://truthinitiative.org/research-resources/emerging-tobacco-products/howmuch-nicotine-juul

3. Stanford Medicine. (n.d.). E-Cigarette and Vape Pen Module. Stanford Medicine Tobacco Prevention Toolkit. https://med.stanford.edu/tobaccopreventiontoolkit/curriculum-decision-maker/by-module/E-Cigs.html

4. Hamilton, J. (2023, May 23). Want to understand your adolescent? Get to know their brain. NPR. https://www.npr.org/sections/health-shots/2023/05/23/1175859398/wantto-understand-your-adolescentget-to-know-their-brain

5. Family Health. (2019, March 19). Nicotine Addiction From Vaping Is a Bigger Problem Than Teens Realize. Yale Medicine. https://www.yalemedicine.org/news/ vaping-nicotine-addiction

6. Hair, E.C., Barton, A.A., Perks, S.N., et. al. (2021). Association between e-cigarette use and future combustible cigarette use: Evidence from a prospective cohort of youth and young adults, 2017–2019. Addictive Behaviors, 112. https://doi.org/10.1016/j. addbeh.2020.106593

7. Barrington-Trimis, J. L., Urman, R., Berhane, K., et al. (2016). E-Cigarettes and Future Cigarette Use. Pediatrics, 138(1), e20160379. https://doi.org/10.1542/ peds.2016-0379

8. Dunbar, M. S., Davis, J. P., Rodriguez, A., et al. (2019). Disentangling Within—And Between—Person Effects of Shared Risk Factors on E-cigarette and Cigarette Use Trajectories From Late Adolescence to Young Adulthood. Nicotine & Tobacco Research, 21(10), 1414–1422.https://doi.org/10.1093/ntr/nty179

9. Watkins, S. L., Glantz, S. A., & Chaffee, B. W. (2018). Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013–2015. JAMA Pediatrics, 172(2), 181–187. https://doi.org/10.1001/ jamapediatrics.2017.4173

10. Levine A, Huang Y, Drisaldi B, et al. (2011). Molecular mechanism for a gateway drug: Epigenetic changes initiated by nicotine prime gene expression by cocaine. Sci Transl Med, 3(107):107-109. doi:10.1126/scitranslmed.3003062

11. Kandel E.R. & Kandel, D.B. (2014). A Molecular Basis for Nicotine as a Gateway Drug. N Engl J Med, 371:932-943 DOI: 10.1056/NEJMsa1405092

12. Castro, E.M., Lotfipour, S., & Leslie, F.M. (2023). Nicotine on the developing brain. Pharmacol Res. 190:106716. doi: 10.1016/j.phrs.2023.106716

13. Leslie, F.M. (2020). Unique, long-term effects of nicotine on adolescent brain. Pharmacol Biochem Behav. 197:173010. doi: 10.1016/j.pbb.2020.173010

14. Tehrani, M.W., Newmeyer, M.N., Rule, A.M., et al. (2021). Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography–High-Resolution Mass Spectrometry. Chemical Research in Toxicology, 34 (10), 2216-2226 DOI: 10.1021/acs.chemrestox.1c00253

15. CDC. (2023). Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults. CDC. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/QuickFacts-on-the-Risks-of-E-cigarettes-for- Kids-Teens-and-Young-Adults.html?s_cd=OSH_ emg_GL0001&gad_source=1&gclid=CjwKCAiAt5euBhB9EiwAdkXWO5iytPSZOlhBlLtuNA IXjhZAPen1O9ap3jGR7h-FlHzYojIBondT9RoCPcoQAvD_BwE

MEDICALEXAMINER

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IF YOU DON’T ENJOY IT, PLEASE TELL US.

Medical Examiner contact information is in the box on page 3 of every issue.

WE’RE BEGGING YOU

We’re never too proud to beg. What we’re begging for is “Everyone Has a Story” articles. With your help, this could be (should be) in every issue of the Medical Examiner. After all, everybody has a story of something health- or medicine-related, and lots of people have many stories. See the No Rules Rules below, then send your interesting (or even semi-interesting) stories to the Medical Examiner, PO Box 397, Augusta, GA 30903 or e-mail to Dan@AugustaRx.com. Thanks!

“And that’s when I fell.”

“He doesn’t remember a thing.”

“I was a battlefield medic.”

“It was a terrible tragedy.”

“I retired from medicine seven years ago.”

“She saved my life.”

“I thought, ‘Well, this is it’.”

“They took me to the hospital by helicopter.”

“Now THAT hurt!”

“OUCH!” NOTHING SEEMED TO HELP, UNTIL...

“The cause was a mystery for a long time.”

“The nearest hospital was 30 miles away.”

“He was just two when he died.”

“I sure learned my lesson.”

“It seemed like a miracle.”

“We had triplets.”

“It was my first year of medical school.”

“It took 48 stitches.”

“The ambulance crashed.”

“I’m not supposed to be alive.”

“This was on my third day in Afghanistan.”

“I lost 23 pounds.”

“At first I thought it was something I ate.”

“My leg was broken in three places.”

“Turned out it was just indigestion.”

“The smoke detector woke me up.”

Everybody has a story. Tell us yours.

TRYTHISDISH

by Kim Beavers, MS, RDN, CDCES

Registered Dietitian Nutritionist, Chef Coach, Author Follow Kim on Facebook: facebook.com/eatingwellwithkimb

What is a zoodle? A zoodle is zucchini cut into long thin strips that resemble spaghetti noodles, except it is a zucchini. This new trend is poised to make eating vegetables a little bit more fun—a trend dietitians and healthy eaters can get excited about!

Ingredients

• 1 teaspoon canola oil

• 2 garlic cloves, minced

• 1 large carrot (cut into long thin strips with a spiralizer or julienne peeler)

• 5 cups chopped Napa cabbage

• 8 ounces shiitake mushrooms (stems removed and tops chopped)

• 8 cups chicken low or unsalted chicken broth

• 1 (5-ounce) can bamboo shoots

• 1 tablespoon soy sauce

• 2 tablespoon miso paste

• 8 ounces cooked or leftover chicken, chopped or shredded

• 2 large zucchini (cut into long thin strips with a spiralizer or julienne peeler)

• 1 bunch green onions chopped

Directions

Place large pot over medi-

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IS DEAD

He just looks friendly. Your fierce defender MEDICALEXAMINER

PRINT WELL, A LOT OF IT IS. There are others that have died in addition to the eight past publications pictured. The Senior News is no more. The Augustan (or “The New Augustan”) seems to have likewise disappeared. And many people say The Augusta Chronicle is a mere shadow of its former self. The good news is that one area publication is alive and well and going strong, and for that we have our loyal advertisers and loyal readers to sincerely thank. If you’re wondering, the name of that publication is shown below:

ASK DR. KARP NO NONSENSE

NUTRITION

Annette, a Facebook friend and an avid cyclist from Savannah, asks

“As a competitive cyclist, I think it would be difficult to get enough protein in my diet without a whey protein supplement.

Am I correct?”

There is a lot of confusion about the need for extra protein, either as whey or any other type of animal or vegetable protein. What peer-reviewed, evidenced-based studies show is that normal, healthy people do not need extra protein. In fact, the average person is consuming too much protein. As for cycling athletes like yourself, the data showing that extra protein increases cycling performance is simply not there. Yes, there is a study here and there, but it’s far from consensus.

What science does show is that if you are a cyclist who is protein malnourished (undernourished), then additional protein would be important. If you already have adequate protein in your diet, then additional protein of any type does not lead to improved cycling performance. In fact, one study published in 2014 in The International Journal of Sport Nutrition and Exercise Metabolism found that whey supplementation impairs cycling performance. Although the findings of one study are not the basis for global conclusions, it should give anyone pause about using their “beliefs” as a foundation for self-prescribed nutrition recommendations rather than evidenced-based and peer-reviewed data.

Most people, including athletes, can get all the protein they need from a simple, healthy, mostly plant-based diet. Surprisingly, people really do not need all that much protein. Protein malnourished Americans are usually found in chronically ill people, in the “oldest-old” (people above 85) who may not be eating well, and in people with certain, specific medical conditions.

Can you meet all your protein and amino acid needs eating plants? Absolutely. Although it is true that many plant proteins are incomplete, which means they may be missing one or more amino acids, different plants have different amino acids missing. Therefore, eating a variety of plants in a meal provides all the amino acids you need for your muscles and

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normal growth, development, and maintenance. For example, in the simple and nutritious dish, red beans and rice, the one amino acid missing in red beans is found in the rice and the one amino acid missing in rice is found in red beans.

When and why did whey powder become so popular? It goes back to the late 60s and early 70s and the newly-formed Environmental Protection Agency. Whey protein makes up about 20% of the protein found in cow’s milk. 80% of the protein found in milk is casein. Remember “Little Miss Muffet, sat on a tuffet, eating her curds (casein) and whey”? In the dairy industry, casein is the crucial

part of milk, used extensively for making cheese. Until the late 60s, the watery whey part of the milk was considered a waste by-product of the cheese industry. It was discarded and usually ended up in lakes, rivers, and streams. When you add a nutrient-rich broth like whey to lakes, it causes algae overgrowth. There was little understanding at that time of the environmental impact of dumping whey and other “waste” dairy proteins into the environment. The problem was what to do with all this waste protein if it could no longer be dumped. The answer was to find marketable uses for whey protein. Now, besides the supplement industry, whey is used in the baking industry and in making a large variety of commercial foods, such as soups, drinks, dips, and protein shakes. Unfortunately whey protein supplementation, especially among athletes, has almost become a religion. Most athletes have their minds made up and do not want to be confused by the facts. Whey has become part of their belief system.

What is the “No-Nonsense Nutrition” advice for today? If you stop to think about the nutrition concerns of most Americans, getting enough protein should not be one of them. Most Americans are overdosing on protein. The focus needs to be on weight reduction, decreasing calories and saturated fat, salt, and sugar, and using carbs as the main energy source for metabolism. Eating all this whey protein is an expensive use of your food dollar, bad for the planet, and unnecessary.

Dr. Karp

Have a question about food, diet or nutrition? Post or private message your question on Facebook (www.Facebook.com/AskDrKarp) or email your question to askdrkarp@gmail.com If your question is chosen for a column, your name will be changed to insure your privacy. Warren B. Karp, Ph.D., D.M.D., is Professor Emeritus at Augusta University. He has served as Director of the Nutrition Consult Service at the Dental College of Georgia and is past Vice Chair of the Columbia County Board of Health. You can find out more about Dr. Karp and the download site for the public domain eBook, Nutrition for Smarties, at www.wbkarp.com Dr. Karp obtains no funding for writing his columns, articles, or books, and has no financial or other interests in any food, book, nutrition product or company. His interest is only in providing freely available, evidencedbased, scientific nutrition knowledge and education. The information is for educational use only; it is not meant to be used to diagnose, manage or treat any patient or client. Although Dr. Karp is a Professor Emeritus at Augusta University, the views and opinions expressed here are his and his alone and do not reflect the views and opinions of Augusta University or anyone else.

TELLING A PATIENT A BITTER TRUTH It was a trailer fire. En route to the scene the firefighters told us there would be one patient in critical condition. Even though it was nighttime we could see the scene from quite a distance because of the intense flames coming from the structure. Despite the efforts of the firefighters the mobile home was going to be completely loss.

We parked the ambulance at a distance because the smoke coming off this fire was especially thick and toxic. As we approached the scene with our cot and equipment one of the firefighters directed us toward a man sitting on the curb a few feet away. He seemed to be in no distress as he sat there smoking a cigarette. In the dark we could see that his shirt was torn and burned and hanging in tatters. I was surprised that with his shirt burned mostly off him, he was still able to sit there calmly smoking a cigarette. Surely he had to have some burns and should be in significant pain.

As we knelt beside him we immediately understood the full situation. We could smell burnt skin and realized that what we took for a burned and tattered shirt was actually his skin. His clothing was burned almost completely away. He was covered with severe burns. He wasn’t having any pain because the majority of his burns were third degree, which destroyed his deeper tissues including his nerves.

We gently urged him onto the cot and began the trip to the hospital asd rapidly as possible. I couldn’t even find an unburned area to start an IV. On the way to the hospital the patient said he felt lucky that his burns weren’t that bad because they didn’t hurt. I told him that he was in fact critically injured. Before we even got to the hospital the tissues in his airway were swelling and he was extremely short of breath. We put him on a ventilator immediately. He was treated and transferred to a burn unit where he died a few hours later. It was hard for me to reconcile that man who was sitting on the curb calmly smoking a cigarette without any pain was dying right in front of me.

OFFICER, PLEASE BACK OFF

I was on call, and a patient had what the ER said was, compartment syndrome of the leg after a crush injury.

That it is one of a few true orthopedic injuries that needs immediate surgical treatment. I had called-out the OR call team and was speeding the mile and a half to the hospital, going about 60 on a 45 mph road. It was 2:30 a.m. and there was no traffic, so I ran stoplights, after slowing to look for cross traffic.

I was pulled over. I told the officer that I was a surgeon headed toward an emergency at the hospital.

He didn’t believe me even after I showed my medical license.

I said I was leaving and he could follow me and verify. I drove off, with him following me (with lights flashing). I pulled into the hospital and parked, and waved him to come in. He didn’t.

I happened to see him pull away about 5 minutes later.

Apparently he had contacted the nursing supervisor and heard that they were about to do emergency surgery, and I was the surgeon.

In another incident I know about, a neurosurgeon lied to the officer and said he was on his way to the hospital, for an

emergency. The officer said, “The hospital is the other way,” to which the doctor said, “and I am lost!” The officer nearly died of laughter.

In our town the police [mostly] knew who every surgeon/physician was, and we were given wide berths, unless we did something really wrong (traffic violations were often overlooked, unless it was for DUI, or one of us caused an accident).

In Louisiana, it is against the law for an officer to interfere with medical care. In smaller cities/towns, they know us by sight anyway. We are there to treat them, too).

CRASH COURSE

More Americans have died on US roads since 2006 than in World Wars I & II combined

What comes to mind when you hear the term “aggressive driving”?

You might conjure up the image of two lowslung souped-up import cars racing each other down the road, weaving in and out of traffic and endangering other drivers in their private speed contest. Or maybe you think of times when you’ve been driving down the interstate and someone flies past you like you’re parked, and you were already going 10 mph or more over the speed limit.

Those are indeed classic examples of aggressive driving. But there are others, including some that you might not have thought about.

Aside from simply speeding, alone or in competition with another driver, aggressive driving also includes deliberately driving in a threatening manner to show impatience, annoyance or open hostility. Examples might include tailgating someone to convey the message that they’re driving too slow. Another way to send that message is to pass the allegedly slow driver and then sharply cut in front of their vehicle the split second the passer’s rear bumper passes the slower car’s front bumper.

Unfortunately, the list of behaviors behind the wheel that fall under the umbrella of aggressive driving is long. We’ve barely scratched the surface.

Another one, a close cousin of the reckless near-miss pass described above, is the person who gets in front of someone who has offended him in some way and then proceeds to “brake check” the other driver. For those fortunate enough to be uninformed about this phenomenon, it describes a lead vehicle using their brakes when there is no reason to stop. A brake check might be just a tap on the brake pedal or a full-on slam on the brakes. This brand of aggressive driving might be due to a road rage incident has been simmering between the two drivers for miles, or it might be caused on the spot by tailgating. The brake check sends a message to the tailgater to back off, but in some cases it seems as though the brake checker actually wants to be hit by the other car. Why would someone pull such a crazy stunt?

Two main reasons are ignorance and emotional immaturity. The driver who brake checks is dumb enough to believe that all rearend collisions are automatically the fault of the rear vehicle. This myth may have once held some validity, but so many vehicles are now equipped with front- and rear-facing dashcams that these days each case can be decided on its own merits, and a brake checker will be found at fault in such collisions. This cancels out a potential third motive: insurance scams.

As for that second reason, no one who is immature enough to get into a potentially violent, even fatal, confrontation with another driver over some trivial offense should be allowed to drive. In fact, laws in a number of states offer judges the option to suspend drivers licenses upon second convictions for aggressive driving.

What about you and me?

The statement was made above that some aspects of aggressive driving might be areas we don’t normally consider. Maybe we think of lead-foot teenagers as being the typical offenders.

But consider this statement from a 2004 United Nations report about road safety: Most people drive aggressively from time to time and many drivers are not even aware when they are doing it

Based on reports from our RTIOs (that’s Roving Traffic Investigators and Observers), there are plenty of aggressive Aiken-Augusta drivers out there who look a lot like librarians, church choir members and school teachers. We have little doubt that most or all would deny that they drive aggressively. But as the UN noted, whether we know it or not, most of us are guilty of aggressive driving from time to time.

Here are a couple of examples from RTIO reports:

• Entering a lane that is about to end to get ahead of one car. By definition a move like this typically involves flooring it* and then cutting off the passed car.

• Merging into the left lane when a car ahead of you is slowing down to turn right. There’s nothing wrong with that except that many such drivers, faced with this temporary slowdown, will squeeze into the smallest space between two cars already in the left lane.

As these two examples demonstrate, aggressive driving doesn’t necessarily involve things like obscene gestures, speeding and road rage. It can happen at safe, slow speeds, and can be so seemingly innocuous that drivers may not even know they’re guilty of it. But plain and simple, even these ordinary moves show aggressive driving. Rather than be inconvenienced or delayed by a few seconds, these drivers let impatience, a lack of manners, and disrespect for other drivers and the law.

So what about me? What about you? Can we allow ourselves a second or two of inconvenience in the interests of safety?

* According to one study, aggressive driving is not earth-friendly, using 37% more fuel and generating more toxic emissions than moderate driving habits, all to gain approx. 2.5 minutes per hour of driving.

EAT YOUR WATER

1-MINUTE MEDICAL

We need food to survive, of course, but the human body runs on water. Human body composition is about 60% water. As simple as water is, its lack can cause dry skin, constipation, and fatigue, and other issues. Left untreated or uncorrected, chronic dehydration has been linked to more serious medical matters like high blood pressure and kidney stones.

Significantly, however, an estimated 75% of Americans are chronically dehydrated. Water, as one patient told an interviewer, is “uneventful.” It doesn’t offer caffeine, sugar, the buzz of carbonation, or much in the way of flavor. No wonder many of us don’t drink as much water as we should.

But there are other ways to get the water we need: we can eat our water. And when we do, the word “uneventful” goes right out the window.

Do you like peaches? They are 88% water. Tomatoes are 94% water. Cucumbers are 96% water. So is spinach. Raspberries, oranges, cauliflower and cranberries are all 87% water. Radishes and zucchini are 95% water. Watermelons, strawberries, and sweet peppers are 92% water. Apricots are 86% water, and grapefruit and cantaloupe are 91% and 90%, respectively.

Are you beginning to get the picture? Consuming water doesn’t need to be flavorless, nor does it need to be delivered in a sugary drink that promotes weight gain and tooth decay. +

listed “suggestive heart failure” on the medical history form.

The blog spot

— posted by Tasia Isbell, on Mar. 17, 2020

7 REFLECTIONS ON GRIEF AND PERSONAL LOSS AS TOLD BY A MEDICAL STUDENT

Being a medical student during your clinical years imparts a certain feeling of invincibility. For many of us, this is our first-time taking care of patients. Our historytaking and physical exam skills are being honed like superpowers. Our clinical knowledge is growing. We begin to take ownership of patients as our own.

With all but two clinical rotations left in my third year and at the peak of my own feelings of invincibility, my dad died.

I showed up for my call shift the next day.

At the time, it seemed the most reasonable action to take as a third-year medical student. It was also the first time I cried in a hospital. I saw the daughter of a dying patient on my service a bit differently. Seeing her at his bedside was different now that my dad was gone. Dealing with loss has and always will be difficult, but being a medical student during your clinical years makes it even more of a challenge. Our professional identities as physicians are still being formed—how we grieve and deal with loss are parts of this identity. Medical education and training do not always prepare us for these moments.

Over the past month of my own journey, I would like to share 7 of my own reflections:

1. Your shift is not more important than your wellbeing. Taking time to process loss is difficult and messy and imperfect.

2. Medicine has never been about textbooks and practice questions and standardized tests. It has always been about people; people who deserve your best efforts to save them, but also for you to feel their loss if the time comes.

3. It is easy to emotionally detach yourself from a patient’s experiences. In those moments, empathy is a necessity. Do not let death and grief steal your empathy, your kindness, your ability to love your family and to help someone else’s.

4. Do not let yourself to be so hardened by loss that you forget the power of feeling. Those very emotions make you human and a much more caring physician.

5. Extend to yourself the same compassion and patience during this time as you would recommend to your patients if they were in a similar situation. You are entitled to your feelings; you are not invincible. It is okay to grieve your family members; it is okay to grieve personal losses. Your lost patients are personal losses. You can cry. You will.

6. Ask for help when you need it. Or if you’re like me, you will have a supportive group of attendings, residents, students, and friends that will force you to leave and take care of yourself. Rely on your classmates and other members of your support system.

One day you will be the resident, you will be the attending, and you will deliver this news to someone else’s loved one. Remember that we can use personal loss as an opportunity to inform how we care for and empathize with those for whom we care.

7. Lastly, take time to find peace—for your sake and your future patients. Processing loss while providing care to others is a superpower that we all need.

EVERYBODY LOVES A GOOD STORY MEDICINE IN THE FIRST PERSON Send your interesting (or even semi-interesting) stories to the Medical Examiner, PO Box 397, Augusta, GA 30903 or e-mail to Dan@AugustaRx. com. Tell us if you want it “by you” or if it needs to be anonymous. Thanks!

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Where have you been?

I had to go up to HR. What for? Did you?

PUZZLE

ACROSS

1. Sleep disorder

6. 1975 blockbuster

10. Fed. med. agency

13. Unambiguous

14. Hawaiian island

15. Bar intro?

16. A movie star is often one

18. _____ glass

19. Consume

20. Temple (Archaic)

21. Rugged

23. Shirts and blouses

24. Hot ______

25. ______-Sinai

28. Furthest back

31. Music hall

32. Tantalize

33. Name for 13 popes

34. R. A. ______ Blvd.

35. Clean and treat a wound

36. Attired

37. Liberty Mutual mascot

38. What flooding rivers do

39. Plants

40. Yellow, crystalline dye

42. Half asleep

43. Thorax, in plain English

44. If you don’t care at all, you don’t give one of these

45. Willows

47. French city on the English Channel

48. Type of mask 51. Wound reminder

52. The act of enrolling 55. Type of bloomer

DOWN

1. Continuous dull pain

2. Court statement

3. Tidy

4. Type of ring

5. Poetry or sculpture, etc.

6. Augusta-born artist Jasper

7. River in central Switzerland

8. Global health org.

9. Secondary category

10. Broad Street restaurant

11. Mr. Barnard

12. Askew

15. Abyss

17. Evening song?

22. Like some steaks

23. Stretched tight

24. Famine’s ironic partner

25. Ancient manuscript in book form

26. Swelling

27. Denounce

28. AU’s Summerville Library

29. Common mall anchor

Heck no! There is no way I can run that far.

30. USA _________

32. The ___ Affair, a diplomatic incident between the US and Britain during the Civil War

35. Items of bedroom furniture

36. It often follows blood

38. She was once married to Gregg Allman

39. ____ assault

41. Monetary unit of Botswana

42. Female deer

44. Seaport in NW Israel

45. Capital of Norway

46. Disfigure

47. Musical symbol

48. Bug

49. Greek temple doorpost

50. The state flags of California, Texas, and North Carolina each have one

53. Nazi beginning?

54. 37-A-like exticnct bird

ETHEBESTMEDICINE

This guy goes to a psychiatrist and reveals that he’s been having bizarre dreams for about the past month.

“What do you mean by bizarre?” responds the psychiatrist.

“It’s basketball games,” says the man. “March Madness.”

“That doesn’t sound so bizarre,” says the psychiatrist.

“I wasn’t finished,” says the man. “The bizarre part is that all the players are donkeys!”

very single day, a man prays that he will win the big jackpot in the lottery. This goes on for years without a win, but the man never gives up.

Then one day at the very moment he said amen he heard a voice from heaven: “Have you considered buying a ticket?”

Moe: What do you call a person who falls down and cracks their skull open?

Joe: Open-minded.

Moe: Why was the landlord seeing a psychiatrist?

Joe: I give. Why?

Moe: Because he was deveoping an apartment complex.

A bystander saw an accident happen and after calling 9-1-1, started to administer first aid to one of the victims.

“How long will the ambulance be?” asked the victim.

“I don’t know for sure,” the Good Samaritan said, “but I would guess around 30 or 40 feet.”

“I see what you mean,” says the psychiatrist thoughtfully. “That is indeed bizarre. Tell you what; I can prescribe medication to help you. Take two tablets an hour before bedtime starting tonight, and I can assure you your crazy dreams will be over.”

“Thank you, doc!” says the man. “You don’t know how much I appreciate this!”

They shake hands and the man heads for the door, but then pauses and turns back to the doctor and asks, “Will it be okay if I wait a couple days before I start taking the pills?”

“I suppose,” the doctor says, “but why wait?”

“The Final Four starts tonight,” the man says.

A salesman at the furniture store told a customer, “This sofa will seat 5 people without any problems!”

The customer said, “Where am I going to find 5 people without any problems?”

A guy checked his homeowners insurance policy and found out if his blanket is stolen in the middle of the night, he’s not covered.

Dear Advice Doctor,

The Advice Doctor

I enjoy my job well enough but I really don’t need the money. I could work for free if it actually came to that and I would do fine financially. I just work to have something to fill my time. Plus I’ve noticed over the years that when people put their feet up and retire, they lose their will to live and sometimes they go downhill fast. Do you think I should keep working?

— I Know I Can’t Keep On Forever

Dear I Know,

You certainly raise an interesting question: what happens when people put their feet up?

As it turns out, there are a number of health benefits. Some of the key benefits include improved blood flow, reduced inflammation, and lower pressure in the veins in your legs.

It shouldn’t be surprising that elevating legs is a good thing. Our circulatory system, engineering marvel that it is, has a huge battle to fight against gravity. Oxygenated blood leaves the heart under some pressure in arteries, while oxygen-depleted blood returns in veins under relatively low pressure. Sitting and especially standing makes the task of circulation that much harder. As a result, people whose job requires standing for long periods of time often experience edema (swelling) in their legs and feet. Pregnancy and some medications can also cause edema in the lower extremities.

As simple as it may sound to simply put your feet up, because swelling of the legs and feet is often the result of some medical condition, it logically follows that checking with your doctor is a prudent first step to take. Elevating legs may not be recommended for every situation.

With your doctor’s green light, it’s time to put gravity to work for you instead of against you. Step 1: get comfortable. Use pillows, folded pads, etc., rather than resting legs on a coffee table or other hard surface. Keep legs slightly bent. The greatest benefit comes from positioning legs above the level of your heart, but if that isn’t possible the more legs are elevated the better. If the position can be maintained for about 15 minutes, that’s optimal.

Use your wheels-up time to read something worthwhile (not on your phone), to meditate, pray, or perhaps resurrect the lost art of writing letters. Improve body and mind in the process.

Thanks for writing. I hope I answered your question.

Do you have a question for The Advice Doctor about health, life, love, personal relationships, career, raising children, or any other important topic? Send it to News@AugustaRx.com. Replies will be provided only in the Examiner.

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THE WINNER: GLORIA MARTIN!

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...wherein

SEVEN

Guillermo Gallardo, MD

Specialist

Paul Butros,

Salman Mufti, MD

Harold Coleman, DPM Podiatrist, Foot & Ankle, Heel Pain

Chanelle Duchaussee, DPM

Janaki Nadarajah, DPM Wound Care Specialist Leg Pain, P.A.D.

Risha Malik, MD

DeAnn Henderson, MD

Komal Quershi, MD