Happy Birthday, More or Less

I turned 55 years old today. Birthdays used to be a day of celebration, but as you age, they become a day of reflection of times past and a reminder of the ticking biological clock that we all watch. Where did it (time) all go?

I started working as a PA at age 22. I almost did not get hired because I was too young. All of my patients in this adult practice were older than me. I was actually the youngest person on staff. Five years later, I started working in a small family practice with lots of kids. About half of the patients were now younger than me. Now, I work in pediatrics. All of the patients are younger than me, as well as half of the doctors. The Circle of a Professional Life.

I was born with very blond hair; nearly white. In high school, my hair became light brown. After college, my hair was dark brown. After a few kids, and age 30, my hair was streaked in silver. Now, for the last five or more years, my hair is white again. I am not going bald. If anything, I have much more hair but growing out of my nose and ears. I have to trim my eyebrows. There are now Sasquatch sightings reported the day after I go to the beach. When I hear a child yell, "Grandpa!" I turn to see if they are referring to me.

I have my health issues, too. I have arthritis, high blood pressure, and I weigh more than I should. I never drank alcohol or smoked, but I love a good chocolate chip cookie(s) from time to time...more often than I should. I don't officially exercise but I am very active, both at work and at home. We have a dust-covered treadmill currently used to hang up my pants. I have some stress, all self-inflicted. We take an active role in grandchildren and aging parents. I work too much, but when you love your job(s), work is part of your relaxation.

I dread going to work today. Our large office makes such a big deal about birthdays. There will be streamers hung all over my office; confetti on my keyboard. A huge cake will be in the break room. Staff and co-workers will be singing "Happy Birthday." (Yeah, right!). They are happy because it isn't their birthday! My little patients will carry off my birthday balloons throughout the day. My wife will buy me something that I will end up paying for on the credit card. I will have a nice meal and perhaps some dessert. Then, it will be over...until next year.

I guess it isn't that bad turning 55. My brother is going to be 63! My wife will turn 60, although most people think she looks considerably younger than me. She doesn't like it when I point out the age discrepancy. By hanging out with these older folks, I can grab at some of the last remaining pleasures of feeling younger.

I plan on retiring from my full-time day job in 11 years, assuming that my savings will permit this departure from the work force. I suspect that I will be still working with WebMD, perhaps from a lap top at my massage chair. (Hold on, let me live that thought for a moment).

I suspect retirement may be boring, but there is nothing like a vacuum of time to fill the void of work around the house. I would like to travel, as long as it isn't with other old people (With the exception of present friends and family). I promise never to wear two types of plaid, even on a golf course. I promise to learn golf. I will not buy a big, gas-guzzling car so that only my head sticks up over the seat. I will drive the speed limit and not slower. I will not have the grandchildren pull my finger, even if it is dislocated. I will not dye my hair and pretend to be younger. I will not walk around the house in boxer shorts and those sleeveless t-shirts. I will watch my diet as long as I can eat what I watch. I will remain physically active, but not climb on the roof anymore. I will not move to Florida or Arizona. I will not move to a manufactured home in a retirement park. I will not buy an RV. I will share my life's wisdom with my grandchildren, even though they may not be interested. I will not ride around on one of those big chair scooters unless I have no other options. I will try and gradually give away all of my stuff so the kids won't have anything to fight over when I'm gone.

And, I will try and have as many birthdays as I can, even though I hate 'em.

Related Topics: Will You Gain Weight in Retirement?, Seniors Urged to Join Medicare RX Plan

Technorati Tags: birthdays, retirement, aging

Mumps: Why does it take an epidemic?

The recent outbreak of mumps in Iowa and seven other Mid-western states is causing an increased demand for the vaccine for the unimmunized. Periodically, nature likes to get our attention and remind us that many of the diseases of the past are still with us. In 2002, there were only 270 reported cases of mumps in the U.S. The Midwest outbreak alone has recorded over a thousand cases so far - the most reported cases in over twenty years. A short plane ride away in England, there were nearly 100,000 reported cases.

The rapid spread of infectious diseases, including this recent mumps outbreak, is due in part to our ability to travel. Before the advent of vaccines, epidemics in the past were often contained by simple quarantine.

If there was a mumps outbreak in one town, the health authorities simply quarantined the town until the outbreak was over. If your child had mumps, local health officers would visit and tack a mumps quarantine sign on your door, warning people to stay away. It was too late for quarantines to contain the 1918 Influenza Pandemic. The flu virus was spread along railroad routes and shipping lines throughout the world. It took over a year for the virus to have global impact. Today, a pandemic strain of flu could become global in a few weeks.

Unfortunately, many viral illnesses are most contagious one or two days BEFORE the classic signs of the illness show up. People inadvertently spread the disease during this asymptomatic period, especially in close quarters, such as an airplane or college classroom/dorm. Mumps can be contagious up to a WEEK before the classic facial swelling occurs.

Mumps is spread by respiratory droplets - a stray sneeze, cough, or any object that is contaminated by these droplets (desks, chairs, tables, door knobs, tissues, etc.). The incubation period can be 12-25 days from the moment of exposure.

Just like nearly every child born in the 1950's, I had an uncomplicated case of mumps in kindergarten. I vividly remember wearing a cotton bandage around my tender cheeks, tied at the top of my head, like some sort of deranged rabbit. I am not sure why I was bandaged, but people felt that it would keep the swelling down (it doesn't).

Mumps affects the salivary glands, usually the parotids, located directly in front of the ears. The salivary glands under the jaw can also be affected. Flu-like symptoms of fever, loss of appetite, and generalized body aches are common. Home diagnosis was made by the "pickle test". My grandmother offered me a sour pickle to eat which resulted in a painful, salivary response. A lemon would also work. We now use serological laboratory tests. Insurance companies do not cover pickles.

Most cases of mumps are not serious; however, there can be serious complications in up to 10% of those affected. Complications such as encephalitis and meningitis are not likely to be life-threatening, but mumps can result in permanent deafness. I had a wonderful couple in my practice that lost their hearing due to childhood mumps.

Mumps can also cause orchitis and oophoritis (painful swelling of the testicles or ovarians, depending on which ones you have). Sterility was always feared when this dreaded complication occurred, but fortunately this was rare.

A single dose of the live mumps vaccine (usually given in combination with measles and rubella - the MMR) will afford 80% immunity. A second MMR will boost this long-lasting immunity to 90%. Of course, if you actually get the disease, nature will grant you 100% immunity.

Children are given the first vaccine at one year; and the second dose at age 4-6 years. According to numerous studies and international statistics, the MMR vaccine is absolutely NOT linked to autism. Anyone who tells you otherwise is seriously misinformed.

Diseases that infected your parents and grandparents are still with us, and thrive just across our borders, or on the other end of your airline destination. Vaccines are safe, and are the best and only preventative measure that makes sense. If you are not immunized against mumps, then you are vulnerable. You better have a jar of sour pickles on hand.


Related Topics: CDC Mumps Information, Adult Immunizations

Technorati Tags: mumps, epidemic, immunization

Teenage Drivers

When I was a teenager, I couldn't wait to drive. Perhaps this was my internal wish to get out of Appalachia, but driving meant freedom.

I started to drive long before doing it legally. We drove on the farm and on the back roads; often with passengers and never with seatbelts. Why? In the 1960s, there were no seatbelt laws and cars were not equipped with them. I shudder at the amount of danger that I experienced as a driver and passenger.

Children stood, unrestrained, on the front seat of moving cars. As a ten-year-old, I stood proudly, like some sort of Presidential candidate, on the back seat of a convertible flying down the highway, with wind blowing through my hair and bugs in my teeth. We drove in mud and drove in snow. As teenagers, we had fender-benders and our only punishment was to go get another fender at the junk yard and fix it. We drove cars of any colors and mismatched parts.

And, yes, there were serious and fatal accidents, too.

Two of my best friends from high school were killed. One drove off the road and hit a tree (he was drunk); and another was a passenger in a Corvette going over 100 MPH when the driver lost control and slammed into a bridge abutment.

When it came time for my own teenagers to drive, I was terrified. Our blended family blessed us with five teenagers at the same time. The oldest one was arrested for driving while intoxicated (we do not drink in our home, but alcohol is commonplace at teen parties). He was traveling home at 2 a.m., going about 10 MPH down the road, trying not to draw attention from the policeman following him. Needless to say, this unusual behavior resulted in his arrest and conviction. A year of license suspension, drunk driver classes, a $1,500 fine, and five years of insurance probation (high premiums) taught him an expensive lesson that was never repeated.

My youngest son, the last of the family to drive, proudly passed his driver's test on a Friday. After relentless begging over the weekend, I allowed him to drive the family car to school on Monday...a four-mile trip. On the way to school, he rear-ended a State Farm Insurance agent whose boyfriend was an attorney. He has never been in an accident since that time, twelve years ago.

Fortunately, none of our children have been injured in car accidents. I can't say that for patients in my medical practice. Every year, we lose patients in our pediatric practice as a result of car accidents. A few years ago, one of our young patients, a popular senior in high school, was killed in front of our office. He lost control of his car, perhaps going too fast on a wet road through a busy intersection, and hit a telephone pole. Flowers, notes, and sidewalk graffiti marked a make-shift memorial for a month.

Earlier this week, I examined a little three-year-old girl for an ear infection. She was accompanied by her father and grandfather. I was told that the family was under some stress. A few days prior, this little girl's mother, Dad's wife, and Grandpa's daughter was killed while taking a walk after dinner. The young driver, distracted while talking on his cell phone, jumped the curb and struck this innocent woman and killed her instantly. I cried.

Teenagers are among the healthiest people on this planet. Watch them play video games or sports, and you will see that their reflexes are sharp and quick. But, when you put highly-distractible, inexperienced drivers behind the wheel of an automobile, judgment often goes out the window.

Stereos are blaring music, girls are putting on lipstick in the rear-view mirror, and boys are looking everywhere but in front of them. Cell phones are being used. Some are even text-messaging. Cigarettes are lit, burritos are eaten, and even books are being read. For teens who can legally carry passengers, you may find their friends unrestrained in seat belts and practicing other terribly disruptive behaviors.

Three Ukrainian teenagers were killed in a car accident a few days ago, coming back from a funeral of another teenager. While passing each other at high speed, one driver lost control and hit an ongoing care head-on. Now, there will be three MORE funerals for families and friends to attend in this close-knit ethnic community. When will it stop?

Laws have been passed to help. In California, like most states, teenagers must have driver's education with road time and pass a written and road test. They are not permitted to carry passengers for one year, unless accompanied by an adult. Teen drivers are subject to the "Cinderella" law, requiring them to be off the road by 11 p.m. Any detectable amount of alcohol or drugs in the system results in an automatic license suspension.

Insurance premiums for teen drivers are astronomical. Does it work? Perhaps some, but not enough. There is even serious talk about raising the minimum age for driving to 18, although studies have shown that drivers 18-20 are still FOUR TIMES as likely to be distracted.

When I discuss the high-risk behaviors of drugs, smoking, and unprotected sex during adolescent physicals, I always mention driving. Why? Driving is the leading cause of accidental death in adolescents. When you hand over your car keys to your teenager on the weekend, know that 53% of teenage driving deaths occur during this time. Although teenagers only represent 7% of the licensed drivers, they account for 14% of the fatalities and 20% of all of the reported accidents. It is not just chronological age, but immaturity.

Accidents happen -- to teenagers and adults. You can't control the weather and hazardous driving conditions can suddenly happen. We know that. It used to be that only screaming and fighting back seat kids caused adults to be distracted. Now, adults are also being distracted by our own mobile toys, like GPS screens, cell phones, wireless Internet palm pilots, CD/DVD players, televisions, and iPods, just like our teenagers.

I even saw an ad the other day for an ice maker for the car. What next? A blender for mixed drinks? A beer tap? A microwave oven?

Parents, it is time to take back some control.

• Set good examples for your children and demonstrate responsible driving at all times.
• Monitor your teen's driving and other behaviors -- know where they are going and what they are doing.
• Let them drive with YOU in the car so you can see first-hand how well they are doing.
• Watch speeding and tail-gating.
• Have zero tolerance to alcohol and drugs.
• Remind them that driving is a privilege, not a right.
• Parents have a right and a responsibility to pull the licenses of their own children.
• Make the consequences known and have the parental guts to stick to them.

Finally, some words to our driving kids: Like all behaviors, you are in charge of your own.

Control your behavior when you are behind the wheel.

• Don't drive aggressively, fast, or inappropriately.
• Control the behaviors of any passengers. Not only do you have their lives in your hands; they may distract you into losing yours.

Related Topics: Teenagers Drive Worse With Male Passengers, Hands-Free Cell Phones Reduce Driving Ability

Technorati Tags: Teen driving, drunk driving, car accidents

Gas Pains

Every human being has suffered from gas pains from time to time. Fearful adults call 911 and head for the Emergency Room when they have severe upper abdominal and chest pain, only to find out after exhaustive cardiac tests that it was just gas ( A "Fart Attack" is really preferable to a heart attack, however).

Grandpas sit in their recliners and proudly proclaim an infestation of barking spiders; much to the delight of their grandchildren who will no longer pull their fingers. Teenagers can belch the alphabet after quickly downing a carbonated drink. I see people with gas-related issues nearly everyday in my practice, but flatulence is not really what I would like to blog about.

With gasoline prices hitting $3.00 per gallon and promises that it will hit $4.00 by the summer, we are facing a crisis. In the U.S., we depend so much on our cars. Compared to other countries, our public transportation is a joke, unless you live in a large city like New York or Chicago. If I had to take public transportation to work, it would take my three hours to go 30 miles and cost me twice as much. Without my car, I wouldn't be able go to meetings, stay late in the office to answer phone calls, or even work after-hours on charts.

I live at the 2,400 foot level in the Sierra foothills, so I could ride a bike...downhill. I would most likely never make it back home again. I could buy a motorcycle that gets 80 miles to the gallon, but I would eventually end up in a wheelchair going much slower. I could buy a hybrid car that gets twice the milage of my small pick-up truck, but how am I going to haul manure and mulch? I could car-pool if I found some other fool that works 14 hours a day in my same office. I could retire early and just stay home and do my Internet-based jobs.

Or, I can just pay it and shut up.

I feel particularly bad for people who are already going from paycheck to paycheck. My own medical assistant is a single mother with four children, one of which could eat enough to run Bill Gates into bankruptcy. She doesn't really have the extra money to spare at the pump. That $50 dollars or more per month that will go for gasoline is going to really hurt. We have twenty more medical assistants and staff in our office in the same financial boat.

World oil prices are going over the top for political reasons. Oil companies are reaping profits they do not deserve. As the dominos continue to fall, prices will increase in just about every aspect of our lives. In no time, you will see costs increase at medical offices, and you will likely pay more for your intestinal gas medication, like Mylicon.

So, high gasoline prices are causing everyone stress. Stress can lead to increased intestinal gas (flatulence). Intestinal gas is partly composed of flammable methane, an alternative fuel source. Now, if we can get our cars to run far enough on intestinal methane...

Related Topics: Fiber Good, And Not Just For Your Gut, Irritable Bowel Syndrome: Herbal Help?

Technorati Tags: gasoline, oil, gas pains

Common Questions about Middle Ear Infections

In my clinical practice and on the WebMD Ear Disorders Board, I get many of these same questions every week.

1. Do all middle ear infections need antibiotics?
No, as a matter of fact, the vast majority of middle ear infections will get better on their own without antibiotics. It will take longer, of course, and there will be several days of pain that will need to be addressed. Our own immune system does a pretty good job in curing many infections. Antibiotics should always be used in very young children (under age six months) or in children who have had complications in the past from untreated ear infections. In Europe, it is commonplace to wait up to a week before antibiotics are started, but these children are examined every three days - often not an option for children in the U.S.

2. My child is immune to amoxicillin now. What other choices of antibiotics can be used?
Amoxicillin is still the drug of choice for treating uncomplicated middle ear infections, but that may change soon. Microorganisms are changing, and we are seeing more and more resistant strains. Your child is not likely immune to amoxicillin, but amoxicillin may not be the appropriate drug for the kind of bacteria that is present in your child's ear. Amoxicillin also has a variable absorption rate and 15% of the population may not be able to absorb it from the gastrointestinal tract. If your child always gets diarrhea or a yeast infection after taking amoxicillin, he may be one of these "non-absorbers".

3. My child hates taking oral antibiotics. Isn't there an antibiotic shot that can take care of it?
Yes. Rocephin will kill about 95-98% of the pathogens that can be causing your child's ear infection, but it isn't cheap and it also hurts. Usually, it is not just one shot that is needed but three, given every day or every other day. The cost to you (or your insurance company) may be $300 to $600 for treating a simple ear infection. Rocephin should be reserved for the most severe or resistant cases. Using Rocephin for a garden-variety ear infection would be like rabbit hunting using a cannon.

4. My new doctor only gave my child five days of antibiotics. Shouldn't ear infections be treated for ten days?
Many medical providers use shortened courses - three days, five days, or seven days. Depending on the child's medical history, age, frequency of ear infections, prevalence of resistant bacterial strains in the area, or day-care attendance (day-care kids tend to have more resistant strains), a shorter course may be quite appropriate. Studies have shown that there are no differences in the outcome.

5. My child is better. Do I really have to complete the full course of the antibiotics? Can't I save half of it for the next infection?
The number one cause of treatment failures and the development of resistant strains of bacteria stems from not completing the prescribed course. Sure, it can be difficult to remember but it is very important. In one study, only 10-20% of the people took their ten-day course of antibiotics. Saving antibiotics is not wise. First, liquid antibiotics expire quickly and lose their potency (look that expiration date!). If you get another infection a month or so later and only take a few days of your left-over antibiotics, you will seriously compromise your treatment if (and when) this fails.

6. Isn't there a vaccine to help prevent ear infections?
Yes and no. The pneumococcal vaccine (Prevnar) was really developed to help prevent more serious childhood illnesses, like pneumococcal meningitis. However, the same bugs that cause this form of meningitis is also the strain the causes some (not all) ear infections. This vaccine is given routinely to all children now and has definitely reduced the incidence of certain types of middle ear infections.

7. Zithromax is my favorite medication since you only have to give it once a day for three days. Why doesn't my doctor use it every time?
Zithromax is an excellent antibiotic and will work for some ear infections. However, recently there has been a shift in the types of bacteria that cause ear infections. Pneumococcus used to be number one, but since the use of the pneumococcal vaccine we are seeing less of this one and more of Haemophilus influenza (not to be confused with the flu). Zithromax will not work for ear infection caused by this organism. Yes, it is convenient. It can even be taken ALL AT ONCE when prescribed that way, but many times Zithromax is not the best choice.

8. Are all middle ear infections painful? My child was perfectly well-appearing and the doctor said he had an otitis media.
Pain is in the mind of the beholder. Some children tolerate discomfort more than others. Yes, an acute middle ear infection can be very painful, especially if there is considerable pressure in the middle ear space. After the immune systems kicks in, along with some pain medication, children can be quite comfortable with a terrible-looking ear. If your doctor sees a bulging, red-yellow eardrum, your child has an ear infection whether he is screaming or not.

9. What is the doctor doing when he puffs air into my child's ear with a bulb attached to the otoscope?
You have a good medical provider. This is called pneumatic otoscopy and is the standard of care in the diagnosis of a middle ear infections. Eardrums can look red, but your child may not have an infection. However, when the doctor puffs air against the eardrum and it does not move in and out normally, this could indicate fluid or pus behind the eardrum - a sure sign of otitis media. A red or yellow eardrum that is bulging and does not move when air is blown against it is a definite middle ear infection.

10. Can parents buy otoscopes to look in their child's ear?
Absolutely. I have recommended parents to use home otoscopes for over 25 years, and have personally taught thousands (not an exaggeration) of people how to use this simple and safe instrument. They only cost about $30...certainly less than an office visit. With some practice and the cooperation of your medical provider, a parent can become quite skilled in using an otoscope. You will still need to see your medical provider if you see a potential ear infection, but it certainly reduce those "false alarm" visits.

Related Topics: Ear Infections: Antibiotics vs. Waiting, Vaccine Cuts Pneumococcal Disease

Technorati Tags: ear infection, otitis media, antibiotics

Antique Medicines, Urinals, and Chewing Gum

I have been a collector of antique medicines since I was a student in the wilds of West Virginia. One day in 1972, when I was traveling between Philippi and Elkins, WV, I stopped at a little store in the town of Bellington (Population: Me and the guy who ran the store). I went into the Golden Rule Company, an old "company store" once owned by one of the coal companies. During the Great Depression many stores closed, but not the Golden Rule Company.

The first thing that I noticed on the candy shelf was a pack of Baby Ruth Chewing Gum (Circa 1925). It was five cents. Next to the gum was a bottle of Glyco-Heroin cough syrup for 27 cents. Heroin? Unbelievable. Sitting on this shelf in West Virginia was a bottle of cough medicine that apparently contained heroin!

Fascinated, I asked him the cost of the gum and cough medicine. Adding quickly, "That'll be 33 cents," he said.

"That cough medicine is really old," I told him.

"Still good. It has the cork in it. And, you can still chew that gum. Okay, you can have them both for a quarter."

I wasn't really bargaining, but I gave him a quarter. A few years later, I wrote the Curtis Candy Company and they were absolutely thrilled to hear about their gum still being sold, nearly fifty years after the gum factory in Chicago had burned to the ground.

As a very poor student at that time, I asked him if he had any other interesting stuff. I followed him up the steps and he opened the door to a cluttered room full of treasure. There were boxes of chaps, bamboo rug-beaters, and boxes and boxes of old medicines.

If I had the money I should have bought EVERYTHING, but I was only interested in the old medicines. I still have the bill of sale for $33.45 of old medicines, one of everything I could find. That was the beginning of my very bizarre collection and fascination with the bygone age of traveling medicine shows and patent medicines.

In the next year, I perused as many antique stores that I could find. Outside of Clarksburg, WV, I met a dear old woman who owned another interesting store. She proudly showed me some of her old medical items, including a shelf of tattered medical books, a few bottles, and something that immediately caugh my collector's eye.

She had two hand-blown glass urinals (male and female) in a display case. I begged her relentlessly to sell them to me. She adamantly refused. A year later, she gave me all of the books for free, since I was the only one she ever met who wanted them. She again refused to part with those urinals.

Nearly ten years after I had moved to California, I was visiting family in Pennsylvania. I decided to drive several hundred miles back to this little store again to see if I could get her to sell those urinals. I now had money. When I arrived at the store, it was boarded up and abandoned.

As I was peering through the dirty and broken windows, a fellow called out to me from a house across the street. He told me that the woman that owned the store was his mother and that she had died five years ago. Nearly everything in the store was sold at auction.

He had no idea about those two urinals and was sort of surprised that I asked. He opened the old store for me. Dust and cob webs were everywhere. There were broken pieces of furniture scattered all about; a few bookshelves with items no one would want.

No urinals. Just junk.

As I shook his hand, something made me open the door of a dusty cabinet. Sitting proudly on the shelf were those two urinals. I couldn't believe my eyes! "How much?" I asked, as I held them for the first time. "I think my Mom must have left those urinals for you. They're yours. No charge."

In a cabinet behind my desk, I have an unopened box of Mrs. Summer's Womb, Ovarian and Kidney Tonic, Train and Sea Sickness pills, Dr. Kilmer's Female Remedy, Dr. William's Pink Pills for Pale People, and about a thousand more. I have cures for diseases such as torpid liver, gleet, and sallowness.

In my garage, I have various quack devices like the Violetta Ray wand with special attachments for any bodily orifice that you can imagine, electric belts, and some unidentifiable things that I am afraid to plug in. My hidden passion is now revealed to you on my Blog.

Late this summer, I will be present for the grand opening of the Gold Country Medical Museum in Auburn, Calif. If you are ever in the area, you will find various antique medical devices, patent medicines, and other quackery items from the "Moser Collection".

I am keeping the Baby Ruth gum. It has four sticks left. Twenty-five years ago, my son, then two years old, chewed a stick, much to my horror. He survived to become an RN.

In 2025, the year my Baby Ruth chewing gum turns 100, I am going to celebrate by chewing one of those sticks myself.

My precious urinals sit proudly on an uncluttered bookshelf in my bedroom. I suspect I will need those, too. Someday.

Related Topics: Pomegranates May Fight Osteoarthritis

Technorati Tags: antiquemedicine, Baby Ruth

Cochlear Implants

In 1984, the FDA approved the first cochlear implant -- a small, highly-complex electronic device that would be surgically-implanted in people who with severe hearing impairment. The news media dubbed it the Bionic Ear.

The cochlear implant is very, very different from traditional hearing aids that amplify sounds. It does not truly restore the hearing for a deaf person, at least, hearing as we know it, but in my opinion, it is a modern miracle nonetheless. A cochlear implant bypasses the damaged or missing part of the delicate inner ear and transmits signals directly to the auditory center of the brain, where these electrical impulses will be interpreted much like the brain processes speech through a normal-hearing ear. A microphone picks up environmental sounds; a computerized speech processor recognizes the "useful" sounds; a transmitter receives those useful sounds and converts them to an electronic signal and sends it on to the brain. Our adaptable brain does the rest and most important job.

In the United States, thousands of adults and children are now using cochlear implants. Children are often excellent candidates for implants, can help them acquire excellent speech and language skills. The happy little girl, pictured in the Blog, came into my office for other medical reasons. Until I noticed her cochlear implant, carefully concealed by her beautiful hair during my exam, I had no idea that she had one. Her speech comprehension and mannerisms were like any five-year-old. She was very proud of her implant.

Many in the deaf community have not embraced this new technology. Why? There are many reasons, but primarily deaf people have already adapted to their silent world; quite well I might add. For anyone who considers a deaf person "handicapped", does not understand the deaf community. They don't feel sorry for themselves at all. They are among the happiest, most-contented, chatty people I know. Many deaf people would not want it any other way. They use Sign Language and read lips. They know more about body language and subtle nuances and visual cues of communication than anyone. They are keen observers, avid readers, quick-witted, and some of the fastest note-writers that I have ever seen.

Some of my deaf patients will bring a sign interpreter with them to my office; most will not. Although medical encounters take a bit longer when you are using written communication, the communication is just as rich and rewarding. When I finally leave to attend to the next patient, I embarrassingly admit that I am still enunciating my words (although I keep my mustache trimmed short, my facial hair can make it a bit difficult for lip-readers), and talking way too loud. Please don't tell any of my deaf patients.

Over the years, I have had numerous deaf couples (one couple even had a deaf cat that they called by stomping on the floor) with hearing children who even whine in sign language. My children were not hearing impaired, but you wouldn't know it if you observed how they ignored me all the time. A child can't ignore a deaf parent - they are in their face, and those kids listen! Seeing a deaf Mom yell at a misbehaving child is a thing of beauty.

Marvin was about 18-years old, deaf, and was on his own for the first-time. Anxious to date, he asked if he could meet with me privately so that I could answer some "sex questions". Of course, I agreed. Counseling is an important part of my primary care practice. A week later, Marvin showed up with a list of questions that would have embarrassed a porno actor. To make matters even more uncomfortable, Marvin bought a little, weeny guy with thick glasses and a bow-tie from the local School for the Deaf to interpret for him. As I read some very explicit questions that Marvin had prepared, I saw this little guy increasingly sweat and squirm in his chair. The question said, "Is masturbation harmful?"

I looked at the interpreter and was very amused by the sign for masturbation -- basically a clinched fist rapidly moving back and forth. Although I do not understand sign language, ANY person would have got that one. I looked at Marvin, repeated the masturbation sign, followed by the universal thumb and index finger circle-sign for "okay". Marvin and I could not stop laughing. The sweat-drenched interpreter did not share in our levity.

Now, back to cochlear implants, which has nothing to do with the previous story. Not all profoundly deaf people are candidates for cochlear implants; and as I mentioned, not all hearing-impaired individuals really see the need. For the people that do have cochlear implants, they seem to love them.

Insurance companies are not fond of anything that costs more than a dollar. Not all insurance companies will pay for cochlear implants; and unfortunately, not all families can afford to pay for them outright. Cochlear implants are very expensive, but life can be just as rich without them.

Related Links: Cochlear Implants Are Better Early in Life, Deaf People Can "Feel" Music

Technorati Tags: Cochlear Implants, Sign Language, Deaf

Hearing Aids - A Brief History

As a long-time collector of antique medical devices, quackery, and medicines, I have always wanted to acquire an old ear trumpet. They show up on EBay from time-to-time, but are always too expensive, or being sold by some dubious person in Romania. Made of tin or hard rubber, these devices were the only thing available for the hearing impaired in the 17th century. The wealthy, of course, had ear trumpets made of gold or silver, encrusted with jewels. As primitive as these devices were, the larger ones did amplify sounds 40 dB or more, depending on the person shouting in to them.

Electronic hearing aids emerged shortly after Alexander Graham Bell patented the telephone. Mr. Bell is often credited for inventing the first hearing aid, but he never patented the device. The first commercial hearing aid, not unlike an old telephone, was produced by the Dictograph Company just prior to the turn of the last century. This was generations before transistors and efficient batteries, so they had huge vacuum tubes and needed to be plugged to the wall. It cost about $400, at a time where you could by a house for this amount in some areas of the country. These early devices only amplified sounds 20-30dB, at best, so ear trumpets were still being used by some your great-grandparents.

By World War II, batteries were smaller and infinitely better, allowing for smaller hearing aids. When I started practicing medicine, the idea that a device in the future could be implanted in the human body to restore hearing would have been pure science fiction. I was born in 1951. The first transistor-based hearing aid was manufactured in 1952. The only assisted-hearing devices available in my youth were devices that just amplified sound - a microphone and a speaker. Many people used a simple device the size of a pack of cards tucked into their front pockets with a very obvious wire leading to their ear(s) with a plain 'ol earplug. The batteries were lousy and only lasted a day at best.

My first experience seeing a child with a hearing aid was Lori, a little four-year old with cerebral palsy, when I worked a volunteer at Easter Seals while in high school. Lori, now married with children of her own, would laugh if she saw this antique hearing device. If manufactured today, with today's technology, they would cost under a dollar. In mid-1960's, the "state of the art" devices were transistorized with small batteries, and located behind the ear. Even then, Lori's hearing aid was so big that it flared her ears outward. Later, she received an "in-the-ear" model, again made possible by even smaller and more efficient batteries.

Next came directional microphones, integrated circuits that allowed environmental sounds to be filtered from speech, to the high-tech, digital, programmable, remote-controlled hearing aids that we have now. These devices are nearly invisible powered by tiny, highly-efficient button batteries. My 90 year-old father-in-law has such a device provided by the Veterans Administration. He lived with us for nearly half a year after he had surgery and was always losing it and accusing the dog of eating it (that happens!).

The rapid advances in hearing aid technology are mind-boggling. For those people out there with hearing difficulties who are considering buying a cheap hearing aid from a magazine ad, you are missing the boat (or at least the sound of the boat). See a good audiologist and have a proper hearing assessment and discuss the right hearing aid for you. We don't all wear the same type of shoes...wear the same eyeglasses. When it comes to hearing properly, you deserve the best that medical science can offer. Yes, these high-tech devices can be expensive, and unfortunately, financial barriers will always be an issue. I wish that it wasn't.

In 1984, the FDA approved an assisted-hearing device quite different than anyone ever imagined - the Cochlear Implant, the topic of my next Blog.

For more on the History of Hearing Aids, read:

• Hearing Aids Through the Ages
• Cochlear Implants (NIDCD)


• Cochlear Implants (AAO-HNS)

Related Topics: Baby Boomers Battle Hearing Loss, Living with Hearing Loss

Technorati Tags: hearing aid, cochlear implant, hearing loss

Things that go cough in the night

One of the most common complaints that we see in a primary care practice is a cough. Often the result of a common cold or allergy, there is nothing more annoying than a persistent cough (Although diarrhea, vomiting, headaches, itching, sore throat, ear pain, abdominal cramps, backache, neck ache, runny nose, and sore feet also compete for that "Most Annoying" category.)

First, why do we cough? Coughing is important to remove unwanted secretions in our airway, whether it is from postnasal mucous, saliva, water, food, or whatever. If it doesn't belong in there, it needs to move out. There are sensitive cough receptors located throughout our airway, including the back of our throats and sinuses, and even in our stomachs and ear canal. Many Q-tip users have experienced a strange, reactive cough spasm when swabbing out earwax. And, as strange is sounds, a wax impaction is one potential cause of a chronic cough. Every time we cough, we irritate those cough receptors, and of course, every time those cough receptors are irritated we cough.

Probably the most common cause of an acute cough in all age groups is a viral infection...a cold. Allergies, including asthma (reactive airway disease) are a close second. Environmental insults such as second-hand cigarette smoke, fumes, and dust can also trigger a cough response. There are literally hundreds of causes of cough, from the more common ones that I just mentioned to some more serious medical problems. Any cough that persists or fails to respond to treatment should be carefully and thoroughly investigated until a cause is determined.

Last Mother's Day, we took my wife, kids, and grandchildren out to breakfast at a popular local restaurant. Needless to say, the place was packed, with people standing outside waiting for tables. Several folding chairs were made available for the more-elderly Moms. The area by the door is also a popular place for smokers, including some of those elderly Moms. I guess it is inappropriate to come down on those smoking Moms on Mother's Day. Apparently, one little child did not know this.

One elderly woman was puffin' away on her cigarette when she was noticed by a little boy about four or five years old, coming out the restaurant. He stopped in his tracks, stared at her for a moment, and then pointed his little finger sternly at her.

"You are going to DIE," he proclaimed. "You should NOT be smoking!" Grandma coughed a few times and smiled. The little anti-smoking advocate was quickly shuffled away into a waiting car. Happy Mother's Day!

Several years ago, my PA wife was working in a family practice clinic. She was seeing a two-year-old girl who had been coughing for nearly a month. Prior treatments for bronchitis and pneumonia were unsuccessful. The child continued to cough.

By taking a careful history of this cough, my wife determined that the cough started suddenly while the child was just sitting on the floor coloring. To make a long story short, a piece of blue crayon was surgically removed from her lungs a few days later.

On both the WebMD Ear Disorders board and the General Health board, we often get questions concerning the relationship of cough to gastroesophageal reflux (GERD). I can tell you by experience, including my own bout last night, that GERD definately causes a cough. As a matter of fact, several years ago I had to stop my ACE inhibitor (blood pressure medication) because of a cough -- a common side effect of this pharmaceutical class.

Children in day-care and schools are exposed to an astronomical amount of diseases that can result in cough. In children, a cough from a common cold can last weeks. When another viral infection jumps in during this period, the cough may be extended for much longer periods of time. These back-to-back viral infections are very common in my clinic setting.

There is a term in medicine called zoonosis, meaning a disease caused by animals. I often see Mominosis, a new medical term that I coined referring to a disease caused by the mother. There is a universal misunderstanding of cold medications: decongestants, antihistamines, cough expectorants, and cough suppressants.

If you give a stuffy child a decongestant (a medication that loosens and drains mucous) at bedtime, when the child is asleep and lying supine you will most definitely cause them to cough. If you also give them a cough expectorant (another drug that encourages you to cough), you are going to be in for a noisy night.

Although cough is medically beneficial, so is sleep...for everyone. In most cases, there is nothing wrong with giving a cough suppressant at bedtime, even though studies have proven them worthless, not much better than a placebo, in children under the age of five. Placebo or not, I let the parents make that decision.

Since colds last a week if you aggressively treat them and about seven days if you leave them alone, anything you are doing is only supportive. Perhaps I am just buying some time to allow the healing process to continue. I do try and make a person feel better while nature does the curing. However, the real goal is to treat the underlying cause of the cough, not necessarily the cough itself.

The last comment that I would like to make is about spitting out mucous. Why is it that men and boys develop this distasteful skill to a high degree? If there was an Olympic Loogie-Hocking Team, it would all be guys. It is important to try and make a productive cough worthwhile, so ladies, please, it is okay to hack up a big one once in a while...in private of course (and not aiming at a tree from a moving car). If you don't cough it UP and OUT, or successfully swallow it, the mucous will come back and bother you again and again.

For more of my Blogs, please click on the Archives (listed by the month) in the column at the right...

Related Topics: Cough Medicines a Bust?, Humidity May Not Help Kids with Croup

Technorati Tags: cough, coughsinkids, coughmedicine

Paper clips - Not just for clipping paper anymore

Paper clips - Not just for clipping paper anymore

I would like to congratulate the inventor of the modern paperclip, Johan Vaaler. Over the years, there have been numerous types of paper clips. As a matter of fact, forensic experts can often date documents by the type of paper clip that was used.

In the daily practice of medicine, paper clips are often a cause of injury (like those people who try and dig earwax out of their ears with them, or the very unfortunately people that accidentally swallow them), and sometimes we use them as medical instruments.

Yesterday, I had ANOTHER child come in to my office with a nasal foreign body. This five-year-old boy decided, for whatever undisclosed reason, that a big, white, plastic bead might be nice to insert in his left nostril.

The big fear of nasal foreign bodies is the potential that the child will snort it back and aspirate it into his lungs. Taking a bead out of the nose is a much easier task that fishing one out of the lungs, I can assure you. Anyway, foreign bodies in the nose can be relatively easy to remove or, in this case, a real challenge. Sometimes, the child has to be sedated or even brought into the operating room.

First step...try and get the child to forcefully blow the nose. By occluding the non-beaded nostril, I tried to get him to simply blow it out. Of course, that is assuming that he knows how to blow his nose - not a universal skill practiced by all children. This little boy was a sniffer. Every time that I asked him to blow he would simply snort it further up his nose, so this was not going to work.

Next step...try and grab it with some forceps. I have a variety of Medieval-looking forceps that I arranged on the table in front of this very apprehensive boy. Selecting a plain 'ol clamp-like forcep, I discovered that it would not open wide enough inside a little nose to grasp this now-slippery (from mucous) bead. It also pushed the bead further up the nose. A special foreign body forcep that opens like a deranged alligator was also tried to no avail. Tweezer-like instruments also failed.

Next, I tried suction. In order for suction to work, you must first have (a) a cooperative patient (I did not), (b) a good suction device, and (c) an object that can physically be sucked out. This bead was really jammed in there and all of my efforts failed to dislodge it.

Next, I tried incorporating the services of the mother. This method has worked for me in the past on younger children. I had the Mom give the child a "little kiss on the lips" - basically instructing the mother to puff some air into the mouth. Sometimes, this will force air out of the nasal passage and dislodge the bead. Again, the five-year-old resisted this very strange technique and it failed.

Having never met a bead I couldn't beat, I starting looking around for some other found objects. I felt a bit like MacGyver. Yes, a paper clip! Using some of my now-discarded instruments, I fashioned my own custom-made bead-retriever. Within seconds, I was able to get behind the bead and pop it out. Bingo! With hundreds of dollars of high-tech medical instruments lying on the exam table a simple paper clip saved the day.

I added this big 'ol bead to the bizarre collection of foreign bodies proudly displayed on my bulletin board, and took a picture of the little boy holding it. The Boo-Boo Gallery is a cute photo display in the hallway of my clinic. Right now, there are several HUNDRED pictures on it and a growing collection of objects fished out of curious kids.

In the past, I have also used a paper clip (heated and sterilized) to evacuate blood under the nail (subungual hematoma) from those people that miss the nail but hit their thumbs with a hammer. I even did this on my own two-year-old when she dropped a big can of baked beans on her toe at the grocery store.

So, thank you, Mr. Vaaler. Little did you realize when you invented the paper clip in 1899, that it would do more than hold our papers together.

Related Parenting Topics: Debate Flares Over Vaccines and Autism, WebMD Children's Health Center

Technorati Tags: objectsinnose, paperclips, children'shealth

Rock Concert Dangers

On the WebMD Ear Disorders message board, I often get questions from people that have recently attended rock concerts regarding their ears. The acoustic levels at concerts vary greatly, but can be extremely damaging. I have people post about hearing loss, tinnitus, and even eardrums that have been shattered.

I have only attended ONE rock concert in my life. Not wanting to date myself, but it was a Beach Boys concert in San Francisco in the early 1970"s. Compared to the heavy metal and hard rock acoustics of today"s bands, the Beach Boys would seem as benign as a Lawrence Welk Show. Having grown up with the Beach Boys in the late 60"s and new to California at the time, I was very excited about seeing them.

I was seated far in the back in the nosebleed seats. The music and crowd noises were deafening. I left that concert with ringing in my ears, and it lasted for a week. That concert was before the speakers and amplifiers were the size of trains. Now, when you attend a rock concert, you put your ears at serious risk.

Early this week, I was scheduled to see a 15 year old with an undisclosed injury sustained at a local rock concert. (Don"t ask me who was playing. I am not into alternative bands). Assuming it was his ears, I prepared my standard stupidity lecture, like not wear earplugs, or being too close to those speakers.

When I entered the room, he was listening to music on his iPod at a respectable volume. He wasn"t seeing me for an acoustic injury at all. He had an injury to his nose! I immediately assumed he was in some type of altercation, perhaps in a mosh pit,

"You are going to love this story", his mother said.

During this very loud and highly-charged concert, this young man migrated closer and closer to the stage, voluntarily, or perhaps being shoved and pushed. Suddenly, without warning, the lead singer dove into the audience for some stage-diving / people-surfing.

As he was being carried by this screaming sea of outstretched arms, the lead singer"s buttocks collided into the surprised nose of my patient. Typical of my sometimes, inappropriate comedic retorts, I asked, "Well, what did it smell like?"

He replied, "I don"t remember, but it sure hurt."

Terrible puns rapidly pulsed through my brain as I tried desperately NOT to comment on the "crack problems" at rock concerts, being ASSaulted, or about his experience of being a true butt-head.

Not wanting to be nosey (Oops, I did it again), I professionally regained my composure, nodded attentively, and sent him off for an x-ray of that butt-damaged beak. No fractures...just another great story to share on the Blog.

One of the more interesting things about medicine is that you never know what is behind that examining room door until you open it.

If I ever go to a rock concert again (unlikely), I will definitely look out for flying butts. In addition to earplugs, I may now start recommending full-face helmets (and nose plugs!).


Related Topics: Rolling Stones: How They Keep Rockin', Baby Boomers Listen Up

Technorati Tags: hearing loss, rock concerts, odd injuries,
broken nose

More on iPods and Hearing Loss

Thank you, Apple. You have listened to the concerns of consumers and health care professionals and have provided us with the software to turn down the volume that has been damaging the ears around the world. That "fix" can be downloaded free from the Apple web site.

I am sure that newer models will not have the same ear-blasting volume potentials. Perhaps threatened by a class-action suit, or individuals claims, or all the negative publicity generated by this issue, but Apple has listened. I thank you on behalf of all of those iPod users who may not be writing to the Ear Disorders Board sometime in the future complaining about mysterious hearing loss or tinnitus.

Apple is a great company. They had no intention of providing a device that will keep ENTs, audiologists, and hearing aid providers in business of years to come. Parents bought those devices for their teenagers because they love them; not because they want to provide yet another reason teens ignore adults. Parents are having enough trouble being heard, let alone deal with children with an acquired hearing disorder.

When I heard the announcement earlier this week about the software fix, I Googled the Net to find it. What I found was even more disturbing. I found a site that will allow you to actually INCREASE the volume of the iPod!

iPods do not cause hearing loss...it is the irresponsible USERS of iPods that are causing hearing loss. iPods have volume controls, folks! Don't just blame the product; blame the product user. These people are making a conscious and personal decision to turn it up to the maximum volume. When the music is so loud that I can hear it coming out of the bobbing head of a teenager 20 feet away, then we have a problem. Of course, the iPod users are not just blue-haired teens, but clean-cut, college-educated, seemingly-responsible adults. I even see ear buds being used while driving. That person will be oblivious to the fire truck siren blaring away behind him.

I remember the protests in California and other states when mandatory helmets were required for motorcycles. How dare the government tell motorcycle riders that they can't have wind blowing through their hair at 80 miles per hour.

I guess the government (US) was getting tired of paying for some of those million dollar bills for neurosurgery. This same government (US) or insurance companies will most likely be paying for hearing aids some time in the future for some of the iPod crowd.

Again, we are simply creatures of our own behaviors. If you are a believer in evolution, or survival of the fittest, perhaps nature will take care of those people flying down the road on motorcycle, wearing an iPod instead of a helmet, smoking a cigarette, after downing a few beers. The tools of our own destruction are always at our disposal.

Parents are going to have to carefully monitor the use of iPods and other personal listening devices used by their children. Download that fix to lower the maximum volume and make sure they don't change it. You need to get them to listen (while they still can) to the rationale, and impress upon them the potential seriousness of acoustic damage. This is not another generation gap issue; this is a serious medical concern. For adults, you are on your own. Apple made a "sound decision". Hopefully, you will make yours.

Related Topics: iPod May Jam Off Pounds, Assistive Listening Devices

Technorati Tags: apple, ipod, volumecontrol, volumefix, hearingloss

Swimmer's Ear -- Not Just for Swimmers

When the ear becomes painful, most people assume it is a middle ear infection, but many times, the problem is in the ear CANAL. The ear canal is lined with skin that is rich in sensory nerves, so an infection in this area can be quite humbling, sometimes even more painful than a middle ear infection.

Swimmer's ear, also called otitis externa, can be caused by frequent water exposure, hence the relationship to swimming. But, exposure to bath or shower water is equally as problematic if the right conditions are present.

The delicate lining of the ear canal is protected by ear wax. When water gets on the wax-coated ear canal surface, it will bead up and fall out when you shake your head, just like water droplets on waxed furniture or your car. However, if you are one of those people who go through a box of Q-tips every month, or routinely swab out their ears after every shower, you are stripping off the protective wax surface and creating the right conditions for an infection.

Swimmer's ear is perhaps the only ear condition that you may be able to accurately diagnose yourself; however, it is still advisable for you to see your medical provider. Obviously, you can't look inside your own ear, but there is a characteristic clinical sign that you can do. Just in front of your ear canal opening is a little area called the TRAGUS. If you have PAIN when firmly push on the tragus like button, or tug on your ears, there is a very good chance you have a condition in your ear canal, such as otitis externa.

In most cases, the standard treatment for otitis externa is a prescription ear solution (ear drops), NOT an oral antibiotic. However, sometimes the ear canal is so swollen, that your medical provider is not able to even touch your ear, let alone carefully inspect it and your eardrum. In this case, your medical provider may elect to do BOTH, although recent studies indicate that this may not be always necessary.

The use (or overuse) of oral antibiotics should be avoided if possible. Severely swollen ear canals may require the insertion of a wick to allow the penetration of the eardrops. This wick is often made with tightly compacted seaweed that gently expands with moisture. As the wick expands, it allows for the eardrops to reach the source of infection or inflammation. Many prescription ear drops also contain a mild anti-inflammatory steroid to help with this swelling. Keep in mind that not all cases of otitis externa is bacterial; yeast and fungal infections of the ear canal are also quite common. These would be treated differently, with an antifungal preparation.

If you have PETs (Pressure Equalization Tubes) in your ears, then you are limited with the type of eardrops you can use. The same goes if your eardrum is ruptured or may be ruptured. Many of the prescription eardrops not approved if your eardrum is open. Some of the newer class of medications, such as Floxin or Cipro HC can be used in this case. Unfortunately, they are more expensive and not currently available generically.

As the warmer, swimming months are approaching, what can you do to prevent swimmer's ear?

1. If you are one of those militant (or secretive) Q-tip users. Stop it! Allow for the protective wax coating to re-establish. Of course, feel free to remove any excess earwax that drains to the outside of your ear. Beneficial or not, this is still unappealing. Needless to say, don't dig around in your ear canal with other found objects.
2. Bacteria (and even yeast) will not grow well in an acidic environment. Incidentally, natural earwax is very acidic. You can make up a homemade acetic acid solution by using half white vinegar and half tap water. Put a few body-temperature* drops of this solution in your ear after a showering or swimming and you will likely prevent most cases of otitis externa. (* All eardrops should be instilled at body temperature. Hold them in your hand for a while to warm them up a bit. Cold drops in the ear can cause dizziness.) You should not use acetic acid drops in your ear if you have tubes or a known eardrum rupture, unless specifically prescribed by your medical provider.)
3. Protective earplugs when swimming or showers can be helpful if you are particularly prone to recurrent otitis externa. There are many types available at your local pharmacy. Cheap, disposable ones are best for children (who lose them). Also, children with earplugs have decreased hearing, so it will be more difficult to yell at them when they are in the pool. Don't put the cat in the pool! No standing on the sliding board! No peeing!

Related Topics: The Lowdown on Ear Candling, New Vaccine May Cut Ear Infections

Technorati Tags: swimmers ear, earwax, antibiotic eardrops