Dr. Thorpe, Chiropractor; Computers in the Hospital; "Off label" use of meds; Benadryl for sleep; Thyroid Cancer & Mammograms; Emergency Rooms are not for primary care; New time slot is 1:30!!!

First, I must admit that I have been remise in saying "thank you" to my colleague Dr. Lorraine Thorpe.  She is a chiropractor, & like myself, she practices in St. Petersburg, FL.  Though we approach the patient from different angles due to our different professions, we are very similar in our committment to the patient & his or her health!  I respect the care she provides to her patients, & I am honored to be associated with her!  Though it may seem strange to some that a Chiropractor and an MD "get along," please realize that they call it complimentary medicine for a reason:  the different approaches to the evaluation & treatment of the patient compliment one another & lead to better care in the long run.  So again, I thank Dr. Thorpe for her sponsorship of the show, & I am pleased that we are all getting to know more about what she does in her chiropractic clinic!

As you have heard many times, I as well as many in the medical profession (doctors, nurses, physical therapists, hospital administrators, etc.) are totally frustrated with the computerization of medicine.  The idea is great, but the implementation is painful, & in my opinion unhealthy!  I find that I spend an awful amount of time running interference trying to find computer errors that otherwise could lead to patient harm.  In fact, I recently read that there are documented cases of several patients dying due to computer errors.  So I would suggest that if you are hospitalized you should pay attention, talk with your medical professionals, & always ask about medicines before you swallow them:  what is it, what is it for, & who ordered it!  Keep notes if you can, & if at all possible, have a friend or family member stay with you to act as your advocate.  It is also a good idea to have a physician who will be your primary care doctor as well as your hospital doctor.  He will already be vested in a relationship with you before your hospital stay, & thus will have better rapport with you & your family during the hospitalization.

We had a question regarding the use of medication "off label."  When a medication is first invented, it goes through rigorous studies to prove it is safe & that it works for a particular disease process (what we call "efficacy").  These studies are overseen by the Food & Drug Administration, & in the end, they review the data & approve or disapprove the medication.  When it is approved, it is "labeled" in regards to how it is used & for what disease processes.  When the drug hits the market, the pharmaceutical representatives set about educating the doctors about it & it's use.  They are not allowed to speak about anything other than what the studies have "proven," but many times physicians use medications in ways that have not been proven.  We do this because we assume that medicines in a similar class will behave similarly.  Thus, if a new anti-depressant hits the market, I will likely use it like I would any other anti-depressant.  A great example of this is a new medicine called Savella.  It is an SNRI (like Effexor), so one would assume that it can be used to treat depression.  But... one would be WRONG!  Forest Pharmaceuticals owns Savella, & they opted to get it to market as a treatment for fibromyalgia.  Thus they did fibromyalgia studies, & ... viola... they proved it helps fibro. pain.  Thanks to these studies, we now can prescribe Savella for treatment of fibromyalgia, but since there were no studies to evaluate it as an anti-depressant, we are not supposed to use it for that.  I pose the question however:  if a person has tried other anti-depressants with poor tolerance or poor response, would you prescribe Savella for him?  Remember, it is an anti-depressant, & we know its side-effects, so in certain situations it might be an appropriate treatment.  I call this "off label" use of medicine the "art of medicine."  It is not always scientifically based, but it is not necessarily quackery or bad medicine.  In fact, it helps determine new uses for old drugs.  Such is the case with Elavil (an old Tricyclic anti-depressant), which is not indicated for, but is commonly prescribed for treatment of chronic pain, prevention of migraine, & treatment of TMJ (temperomandibular joint) syndrome.  If you wonder why we don't do more research to get the label for these disease processes, the answer is simple:  MONEY!  It is not cost effective to spend millions or billions of dollars to get indication for a rare disease, nor is it effective if the drug will soon lose it's patent & go generic.  Doctors have the right to prescribe "off label," but with the ever increasing oversight by insurance companies & the government, as well as the growing legal arena in which we practice, I suspect we will see less of this "art" being practiced in the future!

Irene had called last week regarding Tylenol PM which she took regularly for sleep.  We suggested that she stop Tylenol PM (which has Tylenol AND Benadryl) & instead take only Benadryl (=Diphenhydramine).  She reported she was sleeping well with Benadryl 25 mg 1 1/2 tabs (which is 37.5 mg total) each night with good results.  She wanted reassurance that this is safe to do for years.  The maximum dose of Benadryl is 50 mg 4 times per day, so that is a total of 200 mg per day.  As you can see, she is well below the daily maximum, & is not even at the max for a single dose (50 mg), so I reassured her that this should be safe... & is certainly safer than the Tylenol PM she used to take.  As always, she should be sure to tell her physician that she takes this (& any other over-the-counter meds) so he can help ensure there are no contra-indications with her other meds or medical conditions.

Skip mentioned that Dr. Oz has been speaking about the fact that thyroid cancer is becoming a common cancer in women.  One wonders why women, & why not men.  Well, the supposition is that mammograms might be causing the thyroid cancer!  Though no one knows that for certain (yet), we discussed that there is no harm in asking the x-ray tech who does the mammogram to cover your thyroid with a lead thyroid guard.  Though it is apparently not common practice for them to do this as a matter of protocol, again there is no harm in requesting that they do it for you.  In fact, when you call to make your mammogram appointment, ask if they will use the thyroid guard.  If so, then schedule your mammogram with them. If not, tell them thanks, but schedule with a different x-ray department that will accomodate your request!

We discussed a question posed on the January 29, 2012 blog.  It was in reference to a young lady with abdominal pain & back pain, associated with eating.  You can refer to the blog for more details, but I did respond that she might have a stomach ulcer, as ulcers can cause pain in the middle of the belly (just below the breast bone) which radiates straight through to the back, & which often gets worse when you eat... as the sick stomach must then try to work to digest your food.  I think the teaching point in the story however is not specific to this situation, but rather a general understanding of how Emergency Rooms work.  This patient indicates that she had been to the ER where they had "ruled out" several conditions, but had not made a diagnosis.  Please understand that the Emergency Room is just that... a place to go when you have an emergency!  There the medical staff will evaluate you for deadly conditions, but if they do not find one, they send you home.  It is not their job to DIAGNOSE your illness... they just want to make sure you will not DIE from WHATEVER is wrong with you!  This patient has been to the ER & had a negative work-up.  That does not mean she has nothing wrong, it just means she likely has nothing horrible that is likely to kill her soon!  She absolutely must see a primary care doctor to have a proper evaluation including a history, physical exam, & possibly labwork.  That doctor will either treat her or refer her to a Gastroenterologist (stomach doctor) for further studies.  The point is to not use the ER as your primary care doctor... you will not get the kind of care you need & deserve!

Remember that next week the Skip Show will move to 1:00-2:00 PM Eastern time.  Therefore, Let's Talk Medical with Doctor Gigi will be broadcast at 1:30 PM on Fridays, so look for us in our new time slot!  And don't forget, if you miss the live show, you can still check out the podcast on www.SkipShow.com, or catch this blog... same place & same time!

Here's to our health!


PS  Please feel free to comment on these blogs, or e-mail me with questions or concerns via: DrGigi@SkipShow.com.  If you are not too shy, call during the live show at:  (727)-441-3000 or toll-free at:  (866)-TAN-1340.