More on Medical Office Chaos...

Wow! I love those comments on my Medical Office Chaos blog. Thank you (even to the person that called me a pompous ass, which I am not).

This has opened up a world of future blog topics for me...drug reps, interruptions in a busy day, the "hidden agendas" of patients, dealing with busy people in a busy office, toys in the waiting and examining room, medical providers who "overbook" appointments. I am going to have to quit my day job just to post some of these.

I madly took some notes as I read the many, many comments from ticked-off patients and misunderstood medical office staff/nurses/doctors, so I hope I can address some of the comments in a more general forum.

Why do we book appointments every 15 minutes when we know a visit usually takes longer?
Let's set the stage.

A person has a 9:00 a.m. appointment. They arrive promptly at nine. We have only been seeing patients for an hour, so we can't be too much behind. It take at least five minutes to do the paperwork at the front...check on insurance eligibility, take the co-pay as required by their particular insurance (we don't set the rules on the amount), and update any address or phone number changes.

It is now 9:05 a.m. Assuming that the nurse or medical assistant is pacing around back there with nothing else to do (unlikely), she will call the patient back. Time to weigh in (everyone's favorite). Let me take off my shoes and coat first. Patient tries to explain why our scale is wrong. Vital signs are taken (blood pressure, temperature, pulse). It is now 9:10AM and the doctor only has five minutes left of that 15 minute slot! The patient is escorted to the room and given a gown (usually paper that immediately tears and disintegrates with perspiration in five minutes). The medical provider gives you time to undress. God forbid we walk in early and catch you half way.

It is now about 9:15AM....the end of your appointment. Another patient is registering at the front desk.

This is our dance that happens every day in an ideal world.

If the medical provider isn't interrupted on the way to your examination room by such things as lab reports, calls from x-rays, patients in the hospital, seemingly urgent patient calls about a kid with constipation or green poop, then your visit can begin. As soon as your visit is over, however long that takes, we have to carefully document everything that we did. Our chart notes are a vital component of the visit. Recently, our office went "paperless" so we have to physically type our own notes (dictation has become way too expensive). Fortunately, I am a fairly fast typist, but I see some of my colleagues pecking way over lunch and after the clinic closes, wishing they had taken typing in high school.

We have at least two or more "No Shows" per day. Personally, I love No Shows, because I can catch up on my charts (which I tend save for times I am not physically seeing patients so people will not have to wait). On the other hand, "no shows" are wasted slots that could have been filled by someone really sick. When patients fail to show at all, and do not cancel their appointments, it make it even more difficult to accommodate everyone that wants to be seen.

Same day appointments? We have a policy called "open access". If you want to be seen today, we see you today. Isn't that a novel approach - sick people can actually be seen on the day they are sick. Even if we don't have appointments, we work in the sick ones. If I have a kid with a 105 fever in one room, and a patient bitching about me being late in another room, I am not very sympathetic. However, I do feel that it is important for my medical assistant to up date them on any of these unforeseen delays, and to apologize.

Late in the day appointments? Parents pick their kids up at day care and find out they are sick, have a rash, and can't go to day care without a doctor's note. Guess who gets an urgent call about 4:45PM from a cell phone as the parent rushes in. This is why I have patients until 8:30 PM. I left the office last night at 10:00 PM after making my last phone calls.

Late for appointments? I tend to be easy on the people who are late for appoints since I work in a pediatric office, and little kids don't drive. It's not their fault, so I see no reason to cause undue stress on the family. I agreed to see a child with an ear infection yesterday when the parent was a half hour late. I come to discover once I entered the room, that the parent was another doctor, and OB-GYN. Why didn't she look in her own kid's ear? No otoscope, and the vaginal speculum wouldn't fit in the ear. See, even medical providers need medical care.

Busy medical providers are not necessarily inefficient with time. They are simply busy. We don't waste time, but we rarely have enough hours in the day. We also like to eat occasionally; urinate from time to time, and get home in time to see our kids awake once in a while. Busy providers are often popular providers. Patients refer other patients and our practices grow. We try to staff-up to meet demands, but that is not as easy as it sounds. Patients can choose rude and incompetent providers...they tend to have more time.

I read a study years ago about patients making their own appointment slots in 15 minute increments. If you had several medical issues that you wanted to address, you would sign up for 30 minutes, or perhaps an hour. Assuming that people know in advance how long their visits may take, then this would seem like a workable solution.

The only problem, however, is payment. If we charged by the hour like my automobile mechanic (I saw $95 an hour on the sign the other day), then it would work. It does not work with insurance and HMOs, who set the price years prior, and really do not care how long it takes. A visit is a visit.

For instance, a Medicaid visit may only pay $11.00 for a half hour at work. Assuming there is a 50% overhead (conservative) in a medical office, that nets out $5.50. Doesn't even buy my lunch, assuming I get to eat. This is probably why we prostitute ourselves for free drug rep lunches.

Now I am rambling. Wasting time. Today is my day-off and this blog has been interrupted three times with calls from my office. I knew I should have gone to culinary school. At least I could eat.

Grandparents are good medicine

My grandparents were responsible for providing many of the people in our small town. They had 13 children, who married 13 other people, who produced cousins by the dozens. In a small town, you needed to understand genealogy before seriously dating anyone.

If you looked up "grandmother" in the encyclopedia, you would probably see a picture of Grandma - friendly, overweight, white hair in a bun, big butt, and apron - sort of like a cookie jar. Grandpap was small, very skinny, cigarette-smelling, and sort of scary. My grandfather died of black lung disease when I was about 6 or 7, so most of my childhood memories revolve around my grandmother.

Grandma lived alone, in a tiny, musty-smelling house surrounded by apple trees waiting to be climbed. She had two dogs: The cantankerous Joey, a free-range rat terrier (who actually caught rats in the house!), and Ginger, a mellow collie that only lived in the kitchen. After raising all of those kids, her pets were now her children. So were the grandchildren.

In the summers as a child, I visited her often; nearly every day. She fed me sugar cookies and we just talked. Every year on my birthday, she would send me a card with a dime and a stick of gum. I received my last card when I was in college. She died shortly thereafter, and I always regret spending that dime and chewing that last piece of gum. I wish I had saved it. I loved my Grandmother. She was my connection to history, and we certainly had an interesting family history.

Years after my grandmother died, I uncovered a bit of family history that absolutely shocked me. Apparently, my grandfather spent time in prison for shooting (and killing) someone. My grandfather shot a neighbor that was having a sexual affair with Grandma! Keep in mind that my vision of Grandma was exactly like I described her - overweight, white hair, big butt, and an apron. Who in their right mind would be courting my Grandma??? Of course, she may not have always looked like that when she was younger, but to think of her in a sexual way was very troubling for me. Grandma? Sex? Anyway, this sort of explains why many of my Uncles and Aunts in the family picture do not resemble each other. Our family tree definitely had a few side branches.

I am now a Grandfather with three grandchildren (Grandma had over fifty grand-kids!). My wife is a wonderful Grandmother (Grammy, she prefers). When our oldest child divorced, we had two of them living with us for several months, which cemented the bond that continues to exist. We spend more money on our grandchildren that we ever spent on our kids: trips to Disneyland, toys, ice-skating lessons, dance lessons. You name it; we bought it. We rarely bake them sugar cookies, but we do have them at least one weekend a month. They cry when they have to go home on Sunday. Grammy cries, too.

I am absolutely amazed at the number of grandparents who are raising their grandchildren today. Our pediatric practice has HUNDREDS of these extended families. The real parents may be divorced, missing, in jail, on drugs, or whatever, but thank God for grandparents. I see them struggle on fixed, senior citizen incomes, but the love is obvious. They have stepped in and taken the role of parents...again. These children are blessed to have grandparents who will open their homes...their wallets...and more importantly, their hearts. Perhaps, this will be their most important parting gift in a full life that must end at some point.

Grandparents are good medicine.

Related Topics: Lessons From The Earth's Elders, Grand Parenting

Technorati Tags: family, grandparents

Cellphones in Medical Offices

Yesterday, I saw a little girl in the clinic with a variety of medical complaints. Accompanying her was her father. As soon as I started my medical history, it became apparent that he did not have those answers. He asked to call his wife on the cell phone. We have a big sign on the back of the door banning the use of cell phones in the exam rooms, but under the circumstances, I agreed. Big mistake.

Within seconds, the mother (waiting at home for an appliance repair person) was on the speaker phone and the medical encounter took a turn south. Not only did I have to repeat everything that I just told the father, I now had some three-way dialogues and simultaneous talking going on. Every attempt that I made to shorten this painful phone interaction was thwarted by more questions...more requests...interruptions. I am going to make a bigger PLEASE TURN OFF YOUR CELL PHONE sign.

I would bet that over HALF of my patient encounters are interrupted by a cell phone. Someone is invariably on the phone as I walk in the room. It can take some uncomfortable seconds before that call terminates. I gotta go, Mom, the doctor is here. Or, during the most inopportune moment, the cell phone will ring. Even if no one answers it, we all have to listen to a tinny version of the ring tone song. Surprisingly, may people excuse themselves and answer it! They carry on a brief conversation, hang up, and try to continue on with the medical encounter as if nothing happened. Not only is this practice rude and disrespectful, it can be dangerous.

The practice of medicine does not tolerate interruptions very well. You get a train of thought and then a phone rings. You are writing a prescription and a phone rings. You are reaching a vital point in the medical interaction, and a phone rings. These interruptions are happening to ALL medical providers, not just me.

I have been very close to dumping my Diet Coke on someone's head at a movie theater when they answer a cell phone next to me. Yeah, I'm sitting in a movie. King Kong. Awesome. I am getting real close to losing my professional demeanor in the exam room.

Here's what I'm going to do...

When I come into the room and the patient or parent is on the phone, I will leave and go see another patient. It gives them 15-20 minutes to finish that important call. If they are still on the phone when I come back, I will do it again. I work 12-hour shifts, so this is not a big deal for me.

If I am asked to talk to an absent person that was too busy to come to the medical encounter, I will most likely refuse.

If the phone rings during a visit, I will tell them to answer it. I will leave and come back. Eventually. I may even go to lunch.

Related Topics: Cell Phones Can Blind Drivers, Simplify Your Life

Technorati Tags: healthcare, cellphone, etiquette

Pediatrics, Late Appointments and Chaos

You never know what is behind door #2...

When people have an appointment at 10:45 AM, they more or less expect to be seen at that time, or at least, shortly thereafter. Staying on schedule is a goal that all medical providers strive to accomplish, but unfortunately, we never know what is behind door #2.

When I worked in family practice, it was not unusual for people to not be truthful about the reason for their appointment. Not wanting to share private information with the front desk, they might say "sore throat", but in reality they are having some serious pelvic pain and think they have a venereal disease. The sore throat visit can be orchestrated between physical exam appointments since it is quick and easy; but a diagnostic exam for a woman with abdominal pain is quite involved. When this happens, we have to deal with it, and unfortunately, the other patients will not be seen at their appointment times, perhaps, for the rest of the day! It takes just ONE unexpected event like this to cause schedule chaos.

Then, there are the "Oh, by the way" people. You will spend 25 minutes of a 15 minute appointment slot, only to be faced with an unexpected peripheral issue. As you are leaving the room to rush to your next patient, someone will ask, "What do you think about this black mole on my arm?" Arrrghhhhh! Not that the black mole isn't important. It may be more important than the original reason for the visit, but now we face a dilemma. Should we deal with this "Oh, by the way" now, or have the patient reschedule? Maybe they won't come back and that possible melanoma will spread? We face situations in the clinic like this every day.

In pediatrics, there is always an entourage of people in the room. It is not unusual to see several uncontrolled siblings, one or more women (one of which could be a parent), a possible grandparent, a mystery person, some strollers and luggage. At least one person is talking on a cell phone and there are sounds of a hand-held video game. (Cell phones are going to be another upcoming blog!) One kid is always rolling around on my wheeled stool, bouncing from one wall to the next. Another child is playing with a $500 medical instrument or pounding on the computer keyboard. Have I set the stage properly? Once order has been restored to the room (sort of), and once the sick child is discovered among the crowd and the proper woman is identified as the real mother, the visit can begin. No sooner than the exam is complete, the prescriptions have been written, and you are making a mad dash for the door and the quiet of the hall, you hear those words: "Can you take a look at his ears, too?" Of course, you don't have a chart; you don't have time; and you know this will be a free visit, you take a quick look at the other child. Why? It will take less time to peek in the ear, than the proper alternatives.

People are complex. When you schedule a woman for a routine pap smear, this is what you are planning to do. However, when you enter the room, you are faced with a crying, depressed individual in a paper gown. Clearly, a pap smear is not her main issue today. You patiently listen to her version of the divorce and custody issues, and what a bastard her husband is, or how she may lose her job. You wait and you listen. Tactfully, you try and look at your watch, but you always get caught. Sometimes, you will decide to triage - take care of the situational depression first, rescheduled the pap. Sometimes, and more likely, you do both. This is a 45 minute visit (at least).

Out in your waiting room, people are stirring. They are making quick arrangements for people to pick up their kids at school, or cancelling other appointments. They are waiting and people HATE to wait (even though we call it a WAITING ROOM!). And, I understand that they are ticked. I hate to wait, too.

My next patient has been waiting a nearly an hour in the room. I don't want to go in there, but this is my job. My first goal is to defuse the angry. I apologize for the wait, acknowledge their anger for being inconvenienced. "I am sorry that you had to wait today. I had an unanticipated medical crisis that took more of my time than anticipated. Sometimes, people's medical problems take more than just 15 minutes. I hope that you understand. Someday, YOU will need more time, and I hope the people that have to wait for YOU will be understanding as well. So, how can I help you today?" We both smile, tensions have released, and we complete the visit. As I exit the door, I hear, "Oh, by the way..."

Related Topics: Making the Most of Your Appointment, Kids' Medical Care is No Small Business

Technorati Tags: healthcare, pediatrics, appointments, timemanagement

Hearing Loss: Dealing with our noisy world

Have you noticed that the world is getting louder? The sound levels at the movie theater are deafening. People are hooking large speakers to their home televisions to enhance the movie effect. Kids' toys are loud. When I stop at a traffic light, I can hear the boom box of an adjacent car rattling my windows. Kids are using IPods and hand-held video games in my office that are sooooo loud that I have to tell them to turn it off. They have headphones on, yet I can't even talk to a parent because the sounds are too loud, let alone distracting. Some European countries limit the volume of personal audio equipment to be 100dB (still way too loud). IPod volumes are unregulated in the U.S. can reach deafening 120dB levels.

I only attended one loud concert in my life, back in the mid-1970s. The Beach Boys. I was on the third balcony and the music was so loud that I thought my head would explode. It took days for the ringing to go away. Now, thirty years later, I do have tinnitus (ringing in the ears), and some high-frequency hearing loss. Now, I don't blame that on Brian Williams, but I cannot believe the noise pollution that all of us experience. Every week on the WebMD Ear Disorders Board, some unfortunate person will write, "I attended this concert last week. I stood next to some huge speakers. Now, my ears will not stop ringing and I am afraid I have lost some hearing."

We live in a world of protective devices. Children wear helmets now when they ride a bike (not something I did as a kid). Football players not only wear high-tech helmets, but an array of modern day armor. People wear safety glasses to protect their eyes when woodworking or playing racket ball. Who is protecting our ears and precious hearing? It has been estimated that more than 30 million Americans are exposed to dangerous sound levels on a regular basis and an estimated 10 million already have hearing loss from the noise. Many organizations have taken notice of this growing problem, since noise-induced hearing loss is 100% preventable.

Granted, I like things quiet. I moved to a rural area because of was tired of hearing my neighbor eating breakfast, and even peeing! Of course, I work in pediatrics and yesterday was a cacophony of screaming two-year olds, so I may be a bit more sensitive than other people. I have been meaning to buy a pair of those pricey Bose Noise-Reducing Headphones -- the kind that drown out the noise in an airplane so you can hear the movie better. I don't think I will wear them in the clinic where decibel levels from crying and screaming can reach dangerous levels, but I think I will sure use them at home.

I see factory workers and people at the airport wearing ear protection required by the Occupational Safety (OSHA) administration. Shooters at a gun club wearing ear protection when they target practice. There are 48 million Americans engaged in shooting sports and firearms can produce noise levels to 170 dB. When am I going to see a free box of earplugs available at a concert or for the school marching band? Is it going to take a series of lawsuits from deaf fans before everyone takes notice? In Europe, people are offered ear protection for concerts, but this is not routine in the U.S., even with the recent publicity about the older rockers and musicians that have developed significant hearing loss and tinnitus. Europe also limits the volume of personal audio equipment to be 100dB (still way too loud).

How loud is loud? Many experts feel that prolonged levels above 85dB can cause permanent damage to hearing. Knowing this, why are movie theaters blasting our ears with levels that often reach 100dB? Concerts have levels that start at 100dB and rise to levels above 130 dB. Even echoing sports arenas have 80-100dB levels, depending on the enthusiasm of the crowd.

Our noisy world:

70-75 dB: Vacuum cleaners and washing machines (this is why I let my wife do this)
85 -90 dB: Lawn mower, leaf blower, hair dryer, motorcycle
100-110 dB: Chainsaw, power saw, small firecrackers, snowmobile
120 dB: Thunder storm. IPODs and MP3 players at full volume
100-130 dB: Rock concerts (can reach 150 dB near the speakers)
120-140 dB: Jet takeoffs and yes, even band practice.

What can you do to prevent noise-induced hearing loss?

1. Just walk away. If faced with a noisy environment, just leave if you can. You have to take some personal responsibility in protecting your ears. If you have a noisy workplace, you need to monitor those sound levels.
2. Ear protection, such as earplugs can help. Some can lower the dB level 10-30 dB.
3. Limit the amount of time you are exposed to noise. Give your ears a break.
4. Turn down the volume, and don't be afraid to tell others to do the same. We chastise smokers, so let's get on the noise polluters.
5. Don't buy noisy toys for your kids and then complain about it.
6. If you think you have hearing loss, or have tinnitus, have your hearing professionally tested and see an ENT specialist.

Related Topics: The MP3 Generation: At Risk for Hearing Loss?, Too Much Noise

Technorati Tags: hearing, ipod, mp3

Treat 'em and Street 'em

I worked evening clinic last night, something that I do three days a week. Since people rarely get sick from 8 to 5, having some after-hour appointments has greatly improved the services we provide for our patients. In the past, the medical group would send people to the urgent care facilities or the emergency room. Although a child with an ear infection is not considered a life-threatening problem, it is something that should be managed promptly. Last night we were not particularly busy, so I had a rare opportunity of spending 45 minutes with a worried mother holding a child with a 103 fever and a suspected ear infection. The child actually had a viral infection, so there was little that I could do to shorten the course of this illness, but the time that I spent with this worried patient was invaluable. The mother left with some new knowledge about the therapeutic advantages of fever (she thought there would be brain damage at 103), that children who pull their ears do not necessarily have an ear infection (boys often pull their penises and they don't have a penis infection!), and that fever-causing viral infections are something that children about 6-9 times per year, mostly in the fall/winter months.

Emergency rooms are geared for emergencies - things that may cause a loss of life or limb. When a child comes in at 10 PM with a possible ear infection, they are triaged, often to the bottom of the list. People often do not understand how the triage process works - the sicker patients are seen first; not first come/first serve. Basically, a child and their sleep-deprived parent could sit there for hours waiting for their turn, only to be trumped by an alcoholic with a minor head injury brought in by the police. The longer a family waits, the more frustrating a simple encounter becomes. Having worked both in emergency rooms and urgent care facilities in the past, I know what it is like to finally face a ticked-off mother with a crying, ear-pulling child. After waiting hours, many ER medical providers will quickly make a diagnosis, and basically "treat 'em and street 'em".

I cannot tell you of the number of bogus ear infection diagnoses that come out of busy emergency rooms. It is certainly time-efficient and easy for a provider to say, "Yes, your child has an ear infection. Here is a prescription for amoxicillin", but many times, this diagnosis is pure bull! When you see the same child five hours later in your clinic, before they have even had one dose of an antibiotic, this "ear infection" seems to have miraculously resolved. Now, granted, the child's eardrum could have been red, and some ear infections are so darn obvious after a one-second look that the diagnosis is a no-brainer, but many ear-infection diagnosed children do not have either of these. Why? The child had a fever. Fever causes in increase in blood flow, and blood is RED!

Crying can also make the eardrum red. Diagnosing a middle ear infection is more than just checking for the color of the eardrum...you also need to check for mobility. Many ear infections will not cause the eardrum to be red; some can be yellow, but all children with middle ear infections have a decreased mobility (movement) of their eardrums. It only takes a few extra seconds for a medical provider to puff a little air from a bulb syringe attached to the otoscope to observe for movement of the eardrum. This is called pneumatic otoscopy and it is infinitely more accurate than simply looking at the color of a crying, feverish child's eardrum.

A pneumatic otoscopy is "standard of care" for making a diagnosis of a middle ear infection, but I bet many families have not seen their medical providers use it. ER medical providers, at least the ones that I have seen over the last 30 years, RARELY use a pneumatic otoscope....takes too much time. More importantly, many of those medical providers that have the "treat 'em and street 'em" mentality will not spend the time to explain to a parent that their child does NOT have an ear infection....takes too much time. After hours in a busy, scary ER waiting room, a parent wants to just get out of there. After a long-shift in the ER, the provider may have the same goal.

If medical care was this easy and straight-forward, we would have drive-up windows and antibiotic vending machines.

So, what am I proposing? First, if your child has an ear infection, try and stay out of the ER. Treat the EAR PAIN at home with an appropriate dose (based on weight) of acetaminophen or ibuprofen. Ask your medical provider for a bottle of pain-relieving eardrops (like Auralgan) to have on hand for these after-hour events. Buy a good home otoscope and learn how to use it....this additional information is invaluable. And, finally, see your own medical provider - someone that knows your child - as soon as you can, the next morning, to properly manage this problem. A better philosophy would be to "treat 'em and teach 'em".

Related Topics:Should I Give My Child Antibiotics For An Ear Infection?, Signs and Complications From An Ear Infection

Technorati Tags: clinic,childcare,pediatrics,ear infection,webmd

Why immunize against chicken pox when you can get it for free?

As a young child in Appalachia, I discovered that mothers developed their own immunization program for chicken pox...they purposely exposed us.

Chicken pox lasts about a week and it tends to be very untimely. Children miss school; parents have to stay home and take care of them. Chicken pox is very inconvenient. Wouldn't it be nice if parents could plan when their kids got chicken pox? Well, they did. In the 1950's, innocent and naive children were forced to visit and play with kids that had chicken pox so they could get it, and get it over with. I was one of those victims and lived to tell about it.

Fairchance, Pennsylvania was a small town of a thousand or so people that knew each other. I was probably related, in some way, to just about everyone. Between my two parents, I had about 40 (yes, 40!) aunts and uncles and way too many cousins. When my cousin, David, came down with chicken pox, the word spread quickly in this little mountain community. My mother informed me that I was going to go play at Aunt Betty's house. When I arrived at my Aunt's, I was shocked to see that David was covered by sores. He looked like one of those zombies on Night of the Living Dead. My aunt reassured me that David "just had chicken pox" and needed some company. Two weeks later, as I sat covered with Calamine Lotion, I discovered the true nature of this public health encounter.

The only parents that really see chicken pox today are the ones that did not immunize their children. Although the vaccine is not 100%, it is quite uncommon to see a bad case anymore. The picture on this site is one of my little patients, the daughter of the nurse practitioner who practices in the same building. Obviously, for one reason or another, she was not vaccinated. As you can see from her little face, chicken pox is miserable and can leave some permanent pox marks in some people (I have one from that damned David!).

The immunity from the disease is close to 100%; the vaccine is not. The vaccine costs money; the disease is free....sort of. Before the advent of this vaccine, chicken pox cost the US economy MILLIONS of dollars every year, from medical costs to lost wages of working parents. This was really the first vaccine that was created primarily for economic reasons. Most children who get chicken pox will recover uneventfully, but children can and do die from this seemingly innocent childhood disease.

The varicella (chicken pox) immunization is not perfect. Few things are in this world, but it is sure preferable to the disease in my opinion. I am sure glad that we don't purposely expose kids in infectious diseases anymore. Oh, we actually do. Day-care.


Related Topics: Chicken Pox Party?, Vaccine Chokes Chickenpox

Technorati Tags: chickenpox,vaccine,webmd

INGROWN TOENAIL DAY in the Pediatric Clinic...

Yes, my area of interest is ears, but in a general pediatric clinic, and with my family practice background, I am also the resident podiatrist. For some reason, I am the only one of the group who removes ingrown toenails.

Kids, especially teenagers, absolutely butcher their toenails by trimming them so close, it causes them to ingrow. They become infected...painful...and swollen. The only solution, if this problem continues, is the permanent removal of the borders of the nail and nail matrix. This is a relatively simple procedure, unless your patient is an uncooperative child...or woosy teenager.

Today, I did two toenail avulsions. Both kids did great. Initially, they were concerned about the huge needle that was used to put their toe to sleep, but a soon as that was over.....a piece of cake. Toes require a digital block...you have inject lidocaine entirely around the base of the toe in order to get a good anesthesia. This procedure can be painful....if you hurry. In kids, it is best to give them some control. I tell them to give me a number from 1 to 5, with five being the highest pain. If they have a 4 or 5, I will stop and wait until they give me the okay. I take my time, and even two year olds will sit still for this painful procedure.

After the nail has been removed, I wrap the toe in sterile gauze and draw a picture of how they are to cut their nails in the future....square....straight across....NOT round and the corners dug out!

Related Topics: Take care of your feet, Finding the right shoe

Why make resolutions on January 1st?

Every January, people make a list of New Years resolutions. They figure that they screwed up last year, and this year is going to be different. A change in the calendar does not change your personality. If we are destined to break some bad habits, it shouldn't matter what time of year it is. The best time to make a resolution is when you have the personal motivation to do it...January 1st may not be the right day.

I am no different than other people. I have some significant health concerns of my own and struggle every day in making the changes that I know will prolong my life and the quality of my daily living.

So, what motivates us to make health care changes? Vanity? Health? Fear? Money? Basically, many things motivate us, but every one of us has a "button" that is the big motivator. Many years ago, I took care of an obese woman who was having extreme difficulty sticking to a strict weight loss regimen. She wanted to lose weight for her daughter's wedding, but that wasn't doing it. Her husband promised her a new wardrobe, and apparently that was not the big motivator. One day in the clinic, I notice her wearing an anti-Richard Nixon campaign button. I ask her about it, and she went crazy over her dislike for this controversial President. Then, it hit me. This was the great motivator. I asked her if she would like an incentive to help her lose weight. Of course, she agreed. I ask her to write me a check to the "Re-Elect the President" campaign for $500. I told that unless she reached her weight loss goal in time for her daughter's wedding, that I would mail the check in her name. Guess what? She not only reached her goal, but exceeded it! Her second biggest reward was tearing up that check!

When I was in family practice, I saw some real "train wrecks"...One sedentary man was a diabetic, a hundred or more pounds overweight, a smoker, hypertensive, and had a strong family history of heart disease -- a heart attack in the making. His health frightened me so bad that I wrote him a personal letter telling him how worried I was about his health risks. He missed his next appointment and I didn't hear from him again for months until I visited him in the hospital after his heart attack. The first thing he said to me, with tubes sticking out of every body orifice, was that he was NOW serious about making some lifestyle changes. Perhaps a bit too late, but at least the heart attack got his attention.

Smoking is probably the greatest health hazard created by man. I often wonder why smokers even wear seat belts, or check their cholesterol. Hell, they are going to die from cigarettes anyway.

Anyone can stop smoking, but often there are some "mismatched strategies". I will ask a person if they would stop smoking for a million dollars in cash. They say, "You bet". Then I will ask them if they will stop for a dollar and they just stare at me. Everyone apparently has their price, but his was somewhere between a dollar and a million. If you can do it for a million, you can do it for a buck.

This strategy is very similar to the rich man who asks a woman if she will sleep with him for a million dollars. She thinks about it for a moment, then agrees. He wavers a bit, and then reduces his price to $500,000 cash. Still a lot of money, the woman still agrees. Then, he offers her $20. Insulted, she says, "What do you think I am?" He replies, "I think we have already established what you are, we are just dickering on the price."

For smokers, the fear of cancer is NOT a motivator. However, creating a fear of emphysema may be a motivator if you present it properly. Get a few drink straws from a fast food place. Anytime that you deal with a smoker, ask them to put a straw in their mouth, pinch their nose, and breathe through it for a while. When they tell you they can't, then tell them this is what advanced emphysema from smoking will feel like in a few years. They better get used to it. I chastised a friend for smoking. His answer? "Anyone can stop smoking, but it takes a MAN to face lung cancer." I didn't have a snappy response to that one.

It is truly unfortunate that it takes a serious health crisis for people to get serious. Maybe we are all a bit lazy...a bit oblivious...or "too busy" to make those changes now. Maybe we have failed so many times in the past that we are afraid to try again. Regardless of our personal barriers or excuses, the ravages of our lifestyle risks will continue, often silently as we procrastinate. At some point, we will all die. Basically, good health is the slowest form of dying. Personally, I would like to live long enough to get all of my Social Security money back!

Technorati Tags: 2006resolutions, stopsmoking, healthylifestyle, webmd

Kidney Stones - When Doctors Become Patients

Most people hate going to the doctor, but guess who hates going to the doctor more? Doctors and other medical providers. Yes, we have health problems, too. Most of us ignore the rule: "If you treat yourself, you have a fool for a patient AND a doctor". I just came back from my routine medical check, and I had to force myself not to sit in the little round chair with the wheels....

Now that I am over 50 (54 to be exact), some things start falling apart. Last year, I became a hospital patient for the first time since my appendectomy in high school.

I was examining this cute four-month old when suddenly it felt like someone kicked me in the back. I knew immediately what was happening. Having diagnosed kidney stones on many people in the past, I knew the tides had turned. The pain was incredible. The mother of the child being examined told me that she had a kidney stone in the past and it was worse than childbirth. Great! This is all I need.

Maybe it was the pain that clouds your judgement, but I went in to see yet another patient, informing my nurse that (a) I have a kidney stone, (b) I am in excruciating pain, and (c) I need to cancel the rest of the patients. Not wanting to go by ambulance out the door in front of my staff and pediatric patients, and not wanting to leave my car in the parking lot to be vandalized, I decided that if I took a pain medication, I could drive the 30 miles or so to the hospital ER near my home. Bad decision.

I made it about 5 miles, then stopped to vomit. Got back in the car and made it another 10 more miles before the second retch. I was in so much pain, that I couldn't find the hospital! I finally walked through the ambulance entrance and announced, "I have a kidney stone, and I really need some help!". To make a long story short, the CT confirmed my self-diagnosis, and some IV pain medications put me in a pain-free stupor. Much better.

After an interesting procedure called a lithotripsy where thousands of sound waves bombard the stone to break it up, I am back to my old self-treating self again. I hate being a patient, but I was sure glad that there are doctors out there.

Related Links: Kidney Stones and Diet, Kidney Stones, when to call the doctor

Technorati Tags: kidneystones, doctors, patients

Appalachian Medicine

I grew up in a small, Appalachian town called Fairchance, located in a 'holler below Chestnut Ridge. There were two part-time doctors in town during my childhood, and I only remember one medical visit for a bad earache by 'ol Doc Moats, the doctor that delivered me. Office visits were $3; a house call was $5, and apparently I was too sick to sit in that crowded waiting room so my mother splurged on the house call. Most medical care was provided by my mother, using Tincture of Iodine and clean rags. I did have one ER visit about age 6 when I slid down a pole and ripped my scrotum on a nail, but that's another story...and, I don't like to talk about it.

Dr. Moats was a "shot doctor". He seemed to give an injection of something (usually penicillin) no matter what was wrong with you. This reputation was well-known among us five year olds. I was terrified all day, as I diligently watched for that big, black car to stop in front of our little house. Then, it happened...there he was, all 300 pounds of him, carrying that ominous black bag filled with needles and stuff.

In a panic, I looked for a place to hide, which was not easy in a two-bedroom house. I sought refuge under my mother's bed, carefully determined that I was in the exact center, perhaps out of the reach of adult arms. I wrapped my fingers tightly around the open box springs above me. However, it didn't take long before I was discovered.

I tactfully moved from side to side, as my mother tried desperately to fish me out of my lair. Then, much to my surprise, she solicited the help of Dr. Moats in my capture. Huge, hairy arms probed wildly, eventually grabbing one of my legs. My death grip on those box springs started to fail, and soon, the lower half of my body was exposed. Before I had a chance to react, my pants were pulled down, and I felt the unmistakable sting of the needle plunging into my buttocks. They got me! I scurried back under the bed until I heard his car pull away.

Related Links: Riding Medicine's Wild Frontier, Folk Remedies Part of Child-Rearing Tradition

Tags: healthcare,kids,injections,webmd

Heal thyself - It's okay sometimes!

Ever since the Dawn of Time, people have been trying to doctor themselves, or have others do it for them. The human body is subject to a variety of afflictions and uncomfortable symptoms, but it is not necessary, or even medically advisable to try to treat certain "non-diseases". Believe it or not, most human afflictions go away on their own without the help (or interference) of medical providers.

Your little girl runs to you, crying, holding up a normal-looking finger that was just pinched in a drawer. You perform a quick exam (no cuts, no blood, no bones sticking out), and provide the appropriate care: You kiss the finger and miraculously, it improves. Your child goes back to exploring the drawer again. You have provided psychotherapy, and your daughter's pain taught her another life lesson - one of many she will experience.

PAIN is often a non-disease and does not necessarily need to be treated. Your teenager sprains an ankle while playing basketball. Assuming it is just a sprain; the pain will keep him from going back out on the court, causing further injury. The pain protects the ankle. Over the course of a stressful day, you develop tightness in your neck and a get a tension headache. Instinctually you know this headache is not a brain tumor, so you listen to your body...you relax, take a bath, get a neck rub, even drink a glass of wine. Lo and behold, the headache goes away. The pain got your attention and it went away without medication.

I was at a medical conference a few years ago listening to a crusty, female dermatologist ask about the best pain treatment for a sunburned teenager shown in the slide. Hands went up in the audience as people suggested cold compresses, steroids, pain medications, Aloe vera, etc. "No", she yelled. "There are NO treatments for this type of sunburn! This kid needs to feel the pain of not wearing sunscreen...or a shirt! If they feel the pain, perhaps they won't do it again." All sunburns are preventable and they need pain to help them remember this important, life-saving fact.

"Stop running though the house or you will get hurt!" This common parental warning goes unheeded by the three-year old wearing a cape and brandishing a light saber. A crash is heard, followed by a cry. CRYING is not a disease that necessarily needs treated. Crying is good. It releases pain-relieving endorphins. Crying should also be a welcomed sound for parents. Why? Crying tells you (a) the child is alive and not unconscious, (b) the child is reacting to pain - an important neurological sign, and (c) it is an excellent locator-beacon of sorts - crying tells you where to find 'em. Again, you assess for injuries and find none. Should you kiss the forehead or use this incident as a learning opportunity? This time, you feel that education is more appropriate than medication. "See, what did I tell you?"

Vomiting and diarrhea can be another "non-disease" that may not need treatment. I see children in my clinic 15 minutes after the first barf, and they are still barfing as I see them...on the floor and sometimes on me. Why are they vomiting? The body may have detected a toxin - a poison more or less -- that is being created by a viral infection. The body tries to purge and eliminate it before it causes more trouble, so it makes you vomit. Or, your child eats the entire bag of Halloween candy he hid in his toy box and then vomits. Should we circumvent this important protective mechanism that the human body has developed and immediately give a drug to stop the vomiting? No, leave it alone. Allow the body to naturally do what it has done for millions of years when we threw up from rotten mastodon meat. Neanderthals learned not to do that. Your child needs to know not to eat three pounds of candy corn. Now, obviously if the vomiting associated with stomach flu threatens dehydration, we need to medically intervene, but at least we should allow the body a sufficient time before shoving drugs at it. The same thing goes for diarrhea....another purging mechanism. Diarrhea is basically vomiting out the back door, and in most cases, does not need Kaopectate and Pepto Bismol to improve. Leave it alone. Diarrhea is another natural body response to illness and does not necessarily need to be treated, other than fluid replacement.

For some reason, we feel that every uncomfortable or inconvenient body symptom needs to be fixed. It does not. We have existed on this planet for millions of years before antibiotics...before pain medication....before medical intervention. Now don't get me wrong, I am a practitioner and advocate of modern medicine. I just feel that we should not treat things that do not need to be treated. Simple as that.

Tags: healthcare,vomiting,diarrhea,sunburn,webmd

Coal Miners in West Virginia

I grew up in a coal mining town in Pennsylvania, about 15 miles north of the West Virginia border. We heated our homes with coal. We played on coal piles. Our grandparents and parents were miners and dug coal with a pick and shovel. And, many of my classmates quit school at 16 so they could go to work in the mines. I went to PA school in West Virginia, just a few miles from the recent tragedy where a dozen coal miners died. My heart goes out to those miners and their families. They are not alone in their pain. I knew from childhood that I could never work in a coal mine. I didn't like caves and I didn't like the smell of coal.

If I could count them, at least a dozen of my family members died either in the mines or as a result of black lung or lung cancer. My grandfather, always black from coal dust, died of black lung, probably with a cigarette in his mouth. My father died of lung cancer at age 39, three of my uncles, and so on.

We lived in a picturesque valley in Southwestern Pennsylvania in a town called Fairchance (Don't miss the irony here!) that was often obscured by the yellow haze of sulfur dioxide (a rotten egg smell) from nearby coke ovens. My mother hung clothes in our basement so that they would not get dirty again from the air!

As a child, I breathed this air, as well as the blue air from my parent's cigarettes. I have never smoked in my life *, so it is a wonder I do not have lung cancer.

(* I must admit that I did smoke once. My friend, Tom and I, unable to steal some my mother's cigarettes, decided to make our own tobacco. With the life-wisdom of a 10-year old, we collected a variety of leaves, primarily poison oak, dried them, and rolled them into a huge, poison oak Doobie that we smoked. I was covered with poison oak, inside and out, and never smoked ANYTHING since.)

I worked my way through PA school in West Virginia as a hospital orderly in 1969. One of the more challenging jobs of an orderly is to "clean up the patients" before taking them to their hospital beds. I was not having any luck scrubbing down a nice old fella who was admitted for emphysema. He had coal dust embedded in every pore. The interesting thing about it was that he had retired from the mines 15 years prior! I told him that he had to have his "admission bath". Puzzled, he agreed. I took him to a large bathtub and began the job of de-coaling him. I changed the black water a half-dozen times and shampooed his dark hair, which surprisingly was white! When he saw himself in the mirror with a beautiful head of white hair, he just stared. He had no idea his hair was white. Initially, he blamed it on the hospital shampoo.

Coal miners are good, God-fearing, trusting people. Although they act like going two miles underground to the face of the coal seam is no big deal, it is a big deal, and one of the most dangerous jobs in the world. They do it for money to raise their families. Coal miners make more than teachers in West Virginia. If they are lucky enough not to die in the mines, they often have lifelong health issues as a result of their profession. Mine health and safety regulations have really helped, but coal mining shortens lives regardless.

I have a lump of Pennsylvania coal sitting on my bookshelf, along with a little statue of a coal-miner (incidentally, made from coal!), and my late Uncle Dave's carbide lamp that he used in the mine. They are there to remind me of my roots and the people that I have lost in my life. Today, I will add some flowers in honor of those brave West Virginia miners that lost their lives as well.

Tags: miners,westvirginia,blacklung,lungcancer,webmd

Earwax - Good

People seem to be unusually obsessed with getting rid of earwax. True, earwax can be unsightly, even disgusting to look at, but under that yucky facade is a very beneficial substance. Earwax has an undeserved reputation of being bad or dirty and for centuries, people have tried to remove it using Victorian earwax spoons to bobby pins, and of course, Q-tips*. While traveling in Japan several years ago, I was handed a free sample of the most lethal-looking, eardrum-piercing, earwax shovels that I have ever seen. With the abundance of U.S. attorneys, I doubt you will see this device on store shelves here. (* The term "Q-tip" is a brand name for the most commonly-used cotton-tipped applicators. Since the proprietary name is more or less universal, I feel I can use it in a generic context)

For generations, parents have inspected their children for earwax. The visible presence of earwax somehow reflected adversely on hygiene. If the kids had earwax, then parents were not doing their jobs. Granted, having some brown...or yellow...or orange wax hanging out of a kid's ear is not very appealing. Not only did parents scrub those dirty ears with washcloths and fingernails, but they tried to excavate the ear canal using cotton-tipped applicators - a practice that shoved and packed earwax deeper in the ear canal to the point of causing some significant hearing loss. When parents would complain that their children "just don't listen", they never once considered that they were contributory.

The body can produce some disgusting substances, like nasal mucous (that's snot), toe-jam, bellybutton lint, eye boogers, dandruff, and pus and other bodily secretions. To many, earwax would be very high on this list. You shouldn't judge a book by its cover, and you should judge earwax by its appearance. Why would evolution or the wisdom of our Creator allow for such a nasty substance?

We put wax on our cars. We wax fine furniture to protect it from water. When water hits the surface, it will just bead up and not penetrate the surface. The body creates wax in the ear canal for the same reason...to protect this sensitive skin lining from water. If you strip the wax out of the ear canal, you will leave the skin vulnerable to infection. Earwax is also acidic and bacteria do not thrive well in an acidic environment. Every summer, I treat hundreds of kids for swimmer's ear (otitis externa), mostly because well-meaning parents are cleaning the protective wax out of the ears, leaving the ear canal constantly wet/damp from pool and shower water. If those kids had a bit more earwax, then a simple shake of the head will allow those beads of water to simply fall out. Parents buy Q-tips and leave them around to further encourage daily rituals of cleaning out your ears.

Short of a Twelve-Step Plan to reduce the addiction to Q-tips, education is my best defense. Spreading the word that earwax is good is part of my life's mission, as sad as that sounds. You can keep wiping those noses and butts, and you can even wipe out excess earwax that emerges from the ear, but please...please...please STOP swabbing out the ear canal. Even the makers of Q-tips warn about this practice, but to no avail. The teachings and practices of our parents, grandparents, and great-grandparents go deeper.

Too much earwax can be a problem and result in conductive hearing loss. Assuming your eardrum is intact - not being previously punctured by a Q-tip -- excess earwax can be safely removed by a gentle lavage of warm water. Like other waxes, earwax will melt with the increased heat of warm water. Of course, never put hot water in your ears. As a matter of fact, unless you want to experience vertigo and vomiting, never put cold water in your ears either.

When you read postings on WebMD's Ear Disorder Board, you will find many Q-tip injuries. Last week, a 12 year old completely ruptured her eardrum while using a Q-tip when she accidentally bumped her elbow against a cabinet, shoving the Q-tip through her eardrum. Ouch. Fortunately, the body has remarkable healing powers to fix these things most of the time. Unintentional injuries occur every day. If you use Q-tips deep in your ear, this will happen to you, if it hasn't happened already.

We must learn from the mistakes of others, since we do not have the time to make all of the mistakes ourselves. Ear wax is good. Leave it alone.

Related Topics: Keeping Ears Clean, Home Ear Examination

Tags: earwax,qtip,earinjury,webmd

For a serious health problem, PRESS 1

If you have a serious health problem, PRESS 1.

Having spent the morning dealing with two large businesses - the phone company and the utility company - I have had it with the serpiginous dance that we must go through on the phone in order to access a live human being. For English, press 1....if your problem is an emergency, press 2....if this is something that can wait for later.....press 3, and so on. And finally after frustrating minutes of intense listening to those Interactive Voice Response menus (none of which are really appropriate for the reason you are calling), and you are not inadvertently disconnected, you may finally get to talk to a human being. Hopefully, this person is not the notorious "Answering Service" that puts you on hold again, only to come to inform you that the office is now closed for lunch and to call back again at 1 PM. However, finding an individual with ANY COMPANY that is (a) knowledgeable, (b) courteous, (c) efficient, and (d) helpful is becoming very, very rare. What has happened to customer service?

A medical office is really no different. Our phone response states, "If you have an emergency, hang up and call 911". Nearly ALL of the patients who call our office think they have an emergency, so paramedics are going to be dispatched to take care of pinkeye, diarrhea, toes that may be broken, and any number of self-declared emergencies. But, most people are dutifully put on hold until a live receptionist can get to their call. Granted, we have a very busy pediatric office and have a half-dozen people on the phones in the morning, the wait can still be quite long. For a parent with a pooping and/or screaming child (usually NOT an emergency, but clearly an URGENT problem), this is eternity. Of course, our music on-hold will calm them down. Right! Personally, if I hear "Spanish Eyes" on hold one more time, I think I will have a nervous breakdown.

Once you get the receptionist, only half of the battle has been won. Now, you have to get an appointment. In our office, we recently initiated an "open access" policy....anyone that calls, for any reason, can be seen today. That is really wonderful news for the consumer, but less desirable for the overworked medical provider. I have always had a policy that no matter how busy I was, I could always see one more patient. However, that policy is certainly being strained lately. Maybe I am a softy, because I rarely turn away anyone, and I would never turn away a sick child. One time, I waited over an hour for a child that needed a few stitches. The mother begged me to see her child. They were only ten minutes away. As I was getting in my car, I saw them pull up...kids eating McDonald food! "I had to feed them first; they were hungry!" After a 12-hour, non-stop shift, so was I. I sent them to the ER. I can see it now...three kids in a busy ER, one with a cut lip, and the rest jumping around, hyped up on junk food, and playing with the wheelchairs. They should be in and out of there in six or seven hours. That will teach her!

The WebMD boards are really like "Press 1". We have health experts and moderators monitoring those boards 24/7, but like a busy waiting room, not all postings are addressed in a timely fashion. The General Health board is an incredibly busy site since it is the "catch all" when members cannot find (or don't look for) a disease-specific board to post. Our mission is to help people help themselves to find answers, support from others and to help them learn to navigate the extremely complex and chaotic healthcare system that we have created. For many people, a posting on WebMD is just the first stop - the Press 1 - of a long, and often frustrating road to finding a solution to their health problem.

Dealing with today's health system is really no different than me pushing a dozen or so numbers trying to get my electricity and phone back on after a storm. It is not an emergency per se...I have a back-up generator and a fireplace, as well as a cell phone. Is it urgent? Yes. Would I like to have it fixed now? Yes. Would I like to talk to a human? More than you'll ever know. There is nothing like some good 'ol human kindness that can soothe many of the frustrations of life.

If you are tired of reading this, PRESS "Control...Alt...Delete".

Related Topics: Surfing the Web: Does Your Doctor Know Where You Are?

Tags: healthcare,IVR,automatedvoiceresponse,webmd

Men and Medical Care

When it comes to medical care, men are the biggest babies (present company included). Men absolutely hate accessing medical care. They will stay home with their finger dangling from a severed tendon and think that maybe it will heal. They will ignore tumors growing on their head until it no longer fits under their baseball cap. And, people wonder why men have a lower life-expectancy than women.

Men are taught to be men. Get hurt? Just "shake it off". Get sick? Just wait it out. Have chest pain? It's just indigestion...ignore it. Need a physical exam? Just postpone it. You would think that testosterone somehow lowers IQ when it comes to making preventative medical decisions.

When I tell a man patient they need to drop their drawers for a rectal exam, their eyes widen in disbelief. What? No, you don't need to do that. Yes, I do. No, I don't want anyone putting a finger in my butt! What if you have prostate cancer? I don't care. We have to die from something. Men protect their rectums like a bank safe; the same goes for their genitals. A prostate exam is easy, painless (discomfort is NOT pain), and very, very important. Men hate it, but they don't get any sympathy from women who have to endure annual pelvic exams. or mammograms. I shudder at the thought that someday there may be ballograms. "Just lay them up on this table; you will feel a little squeeze."

Testicular cancer is a young man's disease. Several years ago, a Phillies baseball player was hit in the "boys" with a baseball during practice. At the hospital, it was discovered he had testicular cancer. This accident saved his life. He had to have one cancerous testicle removed. When he returned to his team, they gave him a t-shirt that said, "If you don't let me play, I will take my ball and go home."

A good friend of mine, father of six (including triplet boys) was recently diagnosed with testicular cancer. Fortunately, he seems to have won this battle, but not without months of painful chemotherapy, radiation, and a bone marrow transplant. And, of course, there is Lance Armstrong -- the most famous of all testicular cancer survivors. In spite of the media attention about this terrible disease, don't you think that men would be pounding down the doors of medical clinics demanding a testicular exam? Not on their lives.

For years, we have instructed women to do breast self-examination. They do it and lives have been saved. Men, on the other hand, are usually given a pamphlet on testicular self-exam that they throw away. Some dedicated medical professionals do take the time to instruct men on this practice, but most are not listening. Take off those gloves, and just leave me alone. You would think that men, who spend a considerable part of their day adjusting their scrotums, scratching, or just holding them while watching a football game, would not be repulsed by a testicular self-exam. As a matter of fact, that would be a great excuse. What are you doing? Oh, just doing my testicular self-exam. Sorry.

We really are responsible to take care of ourselves. Medical providers are really just travel agents. Doctors can tell you how to take this journey through life, but we are the ones traveling. Good health is, indeed, the slowest form of dying, but why should we die from preventable illnesses? You should not stand in front of a target while people are shooting arrows; so why don't men try to dodge the arrows of testicular or prostate cancer? Why? They are babies - pure and simple. Many men feel that "what they don't know can't hurt them". Man, are they wrong.

Related Topics: Lie to Your Doctor, Fool Yourself, Prostate Screening Saves Lives

Tags: healthcare,menshealth,testicularcancer,webmd