Going with The Flow in Public

My friend, Shawn Anderson, left on his bike from San Francisco a few days ago, and made it over the Sierras to Carson City, Nevada yesterday. He should be on his way to Salt Lake City across the desert. The last time I went that way, I was in a car (of course). The weather should be in the low 100’s, unless he decides to ride at night (my suggestion). Of course, riding at night has its own hazards, like getting hit by a drunk driver or a distracted 18-wheeler. You can follow his progress on the Extra Mile America web site.

Shawn is a vegetarian, so it can be difficult for him to get sufficient protein and calories on this 3000 plus mile journey he has undertaken. He had some heat exhaustion today, which is not surprising – he is riding a long a blacktop highway that holds and reflects heat, the sun is beating down on him, the air temperature is around a 100 degrees, no shade, and pouring out bodily water like a sweat faucet. I am sure he has one of the hydration packs strapped to his back, but it would not take very long, under those conditions, for the body to lose precious electrolytes like potassium and sodium.

The more you drink, the more you should urinate, unless of course you are losing water in other ways. Sweating and rapid respiration will deplete the body of fluids faster than you can imagine. One might assume that long distance riders or bicycle racers would not need to urinate that often, or do they? Shawn is going for distance and duration, and is not really racing, so I am sure he stops at a convenient roadside rest or gas station, or relieves himself modestly behind a tree (should he find a tree in the middle of the Nevada desert, of course). Men are really anatomically blessed for random urination. We go with the flow, so to speak.

The husband of one of my co-workers is a professional bicycle rider, sponsored by a pharmaceutical company that distributes insulin. His job is to ride in as many bicycle racing events as he can during the year wearing the company logo. During those intense races, I asked him what happens if he needs to pee. I thought it was a good question. I assumed the he stopped at a portable potty and did his thing, but NO! What he told me next both shocked and troubled me.

Without stopping, or even slowing down, he is able to pee on the run! How can this be done, especially when wearing those tight spandex pants? Practice. Practice. Practice. Apparently, Chris has it down to a fine art of whizzing while whizzing by on his bike. He said that during televised races, a camera may zoom in on the act in progress, but will quickly pan out. Apparently, all (or most) bicycle racers have developed this unusual skill.

When we were making a long open-ocean crossing in a kayak, you are supposed to stop, climb out of the kayak; hang on the side of the boat and pee. Sounds simple enough, but climbing back into a kayak in the ocean is not as easy as getting out. Perhaps remember that scene from Jaws where the shark grabbed the legs of a startled swimmer, pulling her under for a meal; my wife decided it would be considerably faster and safer just to pee in her wet suit while in bow of the tandem kayak! After a several hours of paddling in the hot, Mexican sun, it became obvious what she was doing. When we stopped for the day and set up camp, it was her job to wash out the kayak.

We were traveling in Japan several years ago when I saw a man in a three-piece suit urinating along a busy road. He was standing on the sidewalk and peeing into the street. My Japanese friend did not seem to notice. He said they are trained not to pay attention to that sort of thing. Many of the public toilets in Japan are co-ed. My wife was shocked to walk by a busy bank of urinals in active use on her way to a stall. The Japanese may be trained not to look, but my wife is not Japanese. She looked.

You don’t think a great deal about urinating, until of course, you desperately have to go. Men are not as choosy when it comes to locations; an alley is just fine. If there is a dumpster, even better. Women on the other hand want a clean, private toilet. When desperate, women will also circumvent decency and do what they must. Those long dresses with big petticoats in the open prairie must have been convenient for those wagon train crossings.

To pee, or not to pee; that is the question. Is it nobler to just hold it?

The Puppy Countdown

Only a few days to go before Lexi’s puppies arrive. She had an x-ray last week and we spotted a LOT of puppies. The vet estimates about six; maybe seven. Counting those little spines and skulls is not that easy when they are all bunched up in there. We thought we were going to have four puppies (according to the ultrasound), but surprise…surprise!

We have her birthing area all set up (a plastic swimming pool with a lot of blankets and towels) in our bedroom. I suspect she will have the puppies next weekend – 63 days, give or take a few days. I also made an enclosure for the grass area (when they are more mobile) so we can put them outside from time.

It has been a dozen or more years since we bred one of our dogs. Last time, we had to work and missed the whole event. We had our teenage son, Alex, serve as midwife. He still says that it was the most fascinating thing ever. We had five little boys at that time. My wife got out the old puppy pictures from last time and it warmed her heart. Those puppies are soooooo cute. She didn’t want to do puppies again, remembering all of the work involved, but she sure loved them.

The last litter, we kept the smallest puppy (Herman), who tragically died a few years ago as a result of an injury. There was one more puppy left, so we put an ad in the newspaper. A few days later, a woman called to inquire about the dog. She had lost her other Sheltie to old age and was still very emotional about it; even apologizing for calling. She decided to come and see the dog, not sure she wanted to get another puppy this soon. When she came to the door, this little fat puppy ran right up to her to be picked up. When he started licking her face, the lady started to cry.

"He looks exactly like my dog passed away a few weeks ago."

"He looks like his mother, Maggie," I said.

"Maggie! That was my dog’s name! I am going right to the ATM and get the cash. This puppy is going home with me today." It was a match made in dog Heaven.

Each one of those puppies found a wonderful home. We even hosted a puppy reunion on their one-year birthday. Those dogs turned out to be beautiful and intelligent pets, deeply loved by their families. I can only hope that we find such good homes this time.

Maggie, now 14 years old, is still hanging in there. She has cataracts and is mostly deaf. She spends a lot of time sleeping now, but still gets excited when she sees a squirrel – her nemesis. She even caught one by the tail in her early days. She still has the motivation to chase them, but chooses to walk now. She was a very good mother to her puppies, so I hope that Lexi will be, too.

It is really surprising how people become emotionally attached to their pets. My neighbor is one of those crusty, hard-ass guys that hate most other people, but loves dogs. He has yet to replace his dog that died a few years ago, enjoying his freedom now. He would love to be able to pet Lexi, but Lexi does not like him…at all. His biggest fear will be that Lexi’s six or seven puppies will be barking at him, too. I asked him for one of his well-worn, stinky t-shirts that I will put with the puppies. Maybe they will get used to his smell, assuming Lexi doesn’t tear it up.

I will be sure to announce the arrival of these new puppies. I hope that all goes well. I will post again in a litter while (pun).

Senior Discounts

I was offered my first "senior discount" about 12 years ago at a Taco Bell in Michigan. I only had about three dollars in my pocket, so I ordered carefully. When my bill came to considerably less than the three dollars that I had expected to spend, I called this discrepancy to the attention of the teenager behind the counter. I felt he probably added it up incorrectly.

"I gave you the Senior Discount. You people deserve it!"

Seeing how I was only about 46 years old at the time, I wanted to tell him exactly what HE deserved, but I graciously accepted the unsolicited discount and pocketed my unexpected change. Was this a bit dishonest? A little, but I considered the discount compensation for the insult.

Carl's Jr. always gives me a senior discount at the drive-up window (after they see me, of course).

"I am going out on a limb and offering you a Senior discount. Is that okay?"

"Sure. Me and Mother hear really appreciate your kindness, Sonny. Could you chop up that hamburger for us. We left our teeth at home?"

Thinking someone is a senior when he is not is equivalent to asking a woman when her baby is due only to discover that she is just fat. Or, maybe not…since making this mistake is not going to earn you any monetary rewards. Soon-to-be seniors can be a sensitive group.

Life has not been easy on me, so I am starting to look more geezer-like with my white hair, Santa beard (and matching Santa tummy), a bit of an arthritic walk, and a look of wisdom that only comes with advancing age (I added this last one). I am 58 years old now and will soon be attending my 40th High School Reunion. This will be my first reunion so you can sure that I will be Blogging about it come August. I can remotely understand how someone, an idiot perhaps, might mistakenly think I am a senior citizen.

The local movie theater offers a senior discount, but does really post their definition of a senior. Is it 60? 62? 65? Is it when you "feel" or look like a senior? Without posting the age parameters, a senior in high school could really ask for a discount. My wife is over 62, a legal senior in some circles. At 58, I am not a senior by any legal definition. So, I asked them. It was 65.

"Wonderful. Two Seniors, please."

I really felt justified lying at a movie theater because they charge so damn much for popcorn ($8 now) and a large Diet Pepsi ($7.50). Who in the Hell gave them the right to charge this much? It is not bad enough to pay high movie prices; they now want to charge you $6 for a pint of bottle water! The two dollar discount wouldn't even make a dent at the snack bar, so we have other strategies.

With our senior tickets in hand, and my wife lugging a heavy purse full of sodas and some freshly-popped popcorn from home, we went on our merry way. They can bite me. I am still ticked at the theater manager for not allowing my grandson to use the restroom five minutes before the doors were officially opened. After vocalizing that I would give him permission to pee in their bushes if they didn’t let him in, they very reluctantly gave the okay. I suspect they were afraid of those bulging veins on my forehead.

"He’s a little boy, for God’s Sake. Let him pee. He is not going to run amok and terrorize your establishment. He is not going to get in line for popcorn (That’s for damn sure!). He just has to pee and he’s too little to hold it."

I made sure that the other people in line heard what was going on in case I needed them to rush the door and starting kickin’ some butt. Maybe they had to pee, too.

I don’t care about my social status in the community, or how much money I make in my life, I am refusing, on principle, NEVER to buy movie popcorn or soda again. If we are rushed and forget our own snacks, I would rather drink the lukewarm water fountain water and eat candy off of the floor. I am a man of the revolutionary ‘60s. We don't take this crap. If they hadn’t let my grandson use the restroom, we would have BOTH peed in those bushes, hoping to be arrested. Attica! Attica! Civil disobedience, no matter how minor or seemingly insignificant, just feels good to stand up for the decent thing to do. The cast-in-stone rules of society should be flexible enough to allow a three year old to pee. I should really join the Grey Panthers; perhaps change my name to Rod X.

Seniors (real seniors) can qualify for some other good discounts. My senior friend in Arkansas says that seniors get a 10% discount a WalMart, even if you are not a greeter. He gets discounts on his utilities, his taxes, and dozens of other things. As an AARP member (through my elderly wife, of course), I will whip out our card at hotels to get the discount. Why not? Hotels are another place that charges way too much. Seeing how they made my list of the Ten Dirtiest Places a few years ago, maybe they should be cleaning up their acts.

Very soon, we heavily-taxed, working, pre-senior Baby Boomers will decide to finally hang it up and retire. Once that fixed income hits you, seniors all over this country will seek out those discounts wherever they may be, and they won’t be doing it shyly. We will clip coupons out of the newspaper for oil changes and two-for-price-of-one tacos. In a few more short years, I will no longer will I be an intermittent senior…a secret senior…a pseudo-senior. I will soon be a REAL senior, entitled to all honors and privileges, including peeing the bushes if they refuse to let me use the rest room.

Respectfully written,
Rod X

Cursing Helps Ease Pain

Somehow, I always knew this. Why else would carpenters recite an endless list of expletives when they hit their thumbs with a hammer? There was a joke going around a few years ago about a woman who complained that some workmen were using the most-foul language ever. Their boss called them in to address this issue. They denied using any offensive language.

"Jim was up on the scaffold. It was my job to throw him the red, hot rivets. Jim accidentally dropped one of the hot rivets down the back of my pants. All that I said, Boss was, "Really, James... you must be more careful."

Study Shows That Swearing May Help Lessen the Perception of Pain

A recent study seems to prove that cursing actually relieves pain, perhaps releasing surges of morphine-like endorphins. People’s heart rate increases with cursing, which may be in response to adrenalin – the fuel of the "flight or fright" response. Whatever the reason, it does seem to work.

Of course, there is also the Michigan Case of the Cursing Canoeist, where Timothy Boomer used some vulgar language in front of women and children, violating a 105 year old ordinance against this sort of thing. He was eventually arrested and hauled to court. To make an interesting story short, Cursin' Tim was let off with a warning to be quieter next time. I used to live in Michigan, and I can contest that when you fall out of a canoe into some cold, bone-chilling water, you are not going to just say, "Really, Timothy, you must be more careful."

Cussing canoeist's conviction thrown out, along with 105-year-old law

Do I personally curse? Yes, sometimes. It depends on the circumstances. Sometimes, it just seems appropriate. It seems right. I try not to do it around other people, but I can't always guarantee that in the heat of the moment. My dogs often hear me utter some inappropriate words. The other night, while coming home late, I tramped in fresh pile of dog poop in the middle of the sidewalk. Both dogs looked guilty, but I knew it was the old, geriatric dog that did it. This was not physical pain, of course, but emotional pain can be deep, too.

I was putting one of those semi-complicated pieces of furniture from Ikea's – the type that uses some unusual bolts or screws that can only be found in Europe. Of course, it didn’t take long for me to drop an essential one and watch it slowly roll off of the deck into some deep weeds. Without this little part, the project could not be completed. So, I said to myself, "Really, I must learn to be more careful."

Living in a rural area, I have satellite Internet (perhaps the satellite is Sputnik), but it doesn’t always work flawlessly. If I fail to "copy" a posting prior to trying to post it on the web site, I can almost guarantee that the system will go down. The longer and more detailed the posting, the greater the chance it will be lost to cyberspace. Some alien presence, a millennium from now may pick it up in space and wonder why earth people were so concerned about Eustachian tubes. If I lose a particularly-complicated posting, I have been known to utter a few choice words.

My wife was working in our clinic one day when she accidentally hit the top of her head with an open cabinet door. Without thinking, she let out an impressive string of obscenities that would shock a seasoned sailor. When she looked up, still holding her head, there were at least a dozen people within earshot, standing motionless with their mouths gaping. One of the medical assistants simply said, "Lindsey! I can’t believe that came out of you." Believe it.

"Really, Lindsey, you must be more careful."

If cursing really does ease pain, perhaps medical science should really capitalize on this.

"Nurse, I think it is time for my pain pills." Without hesitation, the nurse pours a large glass of ice water or scalding coffee onto your groin.

"Aaarrgh. $&%&%(*^*(^!!! I feel much better now. Never mind."

One of the more challenging (painful) procedures that I perform in my clinic (and you thought I only do ears) is toenail avulsion. Teenagers have this compulsion to dig at their toenails or trim them too short. Eventually, these repetitive acts will result in some painful, in-growing nails requiring surgical removal. Injecting lidocaine into the base of the toe is enough to release out those primitive expletives that they try so hard to suppress. I have heard some interesting vocalizations at times. Even two-year-olds will cuss if the circumstances permit.

I wonder if the type of swear words a person utters is more analgesic than others? For instance, "Oh, Poo" would only be appropriate for a minor, brief pain, whereas the Mother of All Swear Words (Yes, the infamous and frequently-uttered F word) would be useful, say for stab or gunshot wounds. Pain is in the mind of the beholder, so you can clearly see how the choice of swear words could be inappropriately applied by novice cursers. Perhaps we can provide a list of appropriate vulgar words, in ascending order of lewdness, for people to read in situations where pain is anticipated. Tele-prompters could work, too. Experienced cursers would obviously not need help.

Unlike sadistic dentists, most medical providers do not enjoy causing pain. Oh. yes, we are tempted from time to time to inject something "real s-l-o-w", but for the most part, medical providers seek to alleviate pain. We used to take urethral swabs for STD cultures by inserting a cotton swab deep up the penis (there are less-painful tests now). The procedural pain that these non-condom-users experienced became a valuable reminder. Pain is and always will be a great behavioral motivator in certain situations. Like narcotics, analgesic swearing may be addictive.

"You can come down from your tippy-toes now, my friend. Really, you must be more careful next time. Use condoms."

A Day in the Life...

Someone recently posted and thought I was "retired" (I wish). If anyone is curious about my typical day, here is a A Morning in the Life…

8:32 AM
I arrived a bit late for work today; I forgot it was Garbage Day. If you forget Garbage Day, it will ruin your next week. Hauling a heavy can up a long slope is not the morning exercise that I should be doing. At least I didn’t need to stop for gas on the way to work.

8:34 AM
I logged into my computer, grabbed my stethoscope, and went to see my first patient. Olivia, the daughter of one of our medical assistants, was four years old and was very sick. She was just lying on the table. She had terrible cold, pink eyes, a cough, and a left ear infection – another on-going gift from day-care. The last time I say Olivia, she had shoved a large, blue, plastic bead deeply up her nose. Before torturing her with digging it out with some scary instruments, I tried an old technique of having Mom gently blow air into her mouth, attempting to bring the bead down to where I could grab it. Olivia, somewhat annoyed by having Mom blow in her mouth, and of course, this bead thing, decided she would just bit her mother’s lip nearly off! I put six or seven sutures into Mom’s lip and sent Olivia to the ER where she could be safely sedated for the bead removal. She did not bite anyone there.

8:45 AM
LM was just 16 years old, but he was heading off to college in Washington State; hoping to be a physical therapist. He was there for his college physical exam and a few missing immunizations. He was overweight (about 270), but was actively on a diet before starting college. I assured him that college cafeterias are typically not that good, so he should have any problem reaching his goal.

9:05 AM
Sammy was a year old and ate clam chowder for the first time yesterday. She loved it, but was rewarded with a good case of hives. (No, her skin wasn’t clammy!) She didn’t seem to mind them, but the day-care provider thought it was chicken pox. It was not. A little Benadryl and a note for the day-care provider sent her quickly on her way.

9:30 AM
JT, a 14 year old, didn’t show up for his appointment. Missed appointments are not that unusual for Monday mornings. I don’t know why I was seeing him, but the illness may have self-resolved, or perhaps, he didn’t come home last night. More likely, he slept in or the parents forgot.

10:00 AM
JT had a rash on his hands. This is starting out to be “skin day”. The parents were camping and God knows what this three-year old touched; could have been anything from poison oak to bear poop. The rash was limited to the palms of the hands, mostly the right hand (his dominant hand). There are no tests that will prove what he touched, so the only thing that can be done is to treat what you see. A good topical steroid cream should solve the issue.

10:12 AM
IL was here for an annual physical exam, but as luck would have it, he also had right ear pain and a bad cold. He is an active swimmer. Though uncommon, he did have otitis externa (swimmer’s ear) and a case of otitis media – a middle ear infection. He was given a prescription for some antibiotic-steroid drops for his ear, but since his middle ear infection was not that bad, I negotiated with the mother about a WASP prescription (means “Wait and See Prescription”). She was given a written prescription for an oral antibiotic and told not to use it unless he is getting rapidly worse, or not improved in three days. Getting parents to agree to use less oral antibiotics is very important.

10:25 AM
EV (and his mother) both had warts, and both were on their feet. Mother had been treated with a blistering agent (probably cantharidin) by her dermatologist and had painful experience. Cantharidin is an extract of the “blistering beetle”, also called Spanish Fly. I decided to do liquid nitrogen. This cryotherapy agent stings, too, but only for a little while. At the end, I use the leftover liquid nitrogen to freeze their hats or shoes, or throw it on the floor. It makes them forget the pain.

10:40 AM
LH is 8 years old and here for her annual physical, too. I had seen her several times for sore throat and ear infections, but now she was well. A year ago, she swallowed (and naturally passed) a good sized rock. What is it with kids and foreign bodies? If they have an object that could possibly fit into some orifice, they will try it. She says she is learning to play a guitar. When I asked her if she liked “rock music”, she laughed.

11:01 AM
KB is a two-year old who was brought in by her father today for a possible ear infection, although she has not been complaining about any ear pain. Because of a past history of ear infections, he was concerned because she had been feverish and crabby. Since starting day-care in September, KB has had a constant, green runny nose and a night cough. She did not have an ear infection today, but I was impressed by that ten month history of a green runny nose with huge amount coming down the back of her throat. Perhaps an exaggeration, but still, that is a lot of snot under the bridge. Her tonsils were huge and exudative (lots of white cheesy material). Her rapid strep test was negative. Rather than sedate her and order a sinus CT scan for a definitive diagnosis, I decided to treat her. I would bet that green snot will be history, or at least for a while, until she gets another day-care infection.

11:20 AM
Four-year old KB was crying when I came into the room. She was crying because Mom informed her that she will need some “shots” for kindergarten. I promised that I would give her “boosters” instead of shots (same thing, but a nicer word), and that I would use the needles that we used for babies instead. If any of those boosters hurt, all she had to do was tell the nurse and the nurse will take it out right away. Kids like to have choices, and some control. Who doesn’t? She left eating one of our sugar-free lollipops and seemed quite happy.

11:40 AM
My last morning patient was a translation challenge. Newborn baby with a large umbilical hernia that is very troubling to the Spanish-speaking grandmother. She has been tightly binding it (not a good idea). The mother, also Spanish speaking, happens to be deaf. My Spanish is not so bueno. Fortunately, the Internet was able to provide me with some excellent resources (in Spanish) about umbilical hernias.

12:10 PM
I am eating lunch at my desk; answering phone messages and checking lab work. Checked my postings on the WebMD Ear, Nose, and Throat board. Getting ready for eight more hours of patient care. These 12-hour shifts are not as easy as they used to be, especially since I do two of these in a row.

12:30 PM
Another person walked in without an appointment. It is a new mother, crying, with her newborn baby (age 12 days). Apparently, while changing her clothes, she accidentally pulled on the umbilical cord and it started to bleed a little bit. Fearing that she caused some major trauma, she wanted her to be seen immediately. Needless to say, the infant was fine, so I spent the remainder of my lunch calming down the distraught mother. Two belly-button issues in a row, and I thought this was going to be skin day.

1:00 PM
I have about a half hour to finish this Blog, before it is time for the afternoon and evening sessions with even more interesting patient encounters. Only eight more hours before I get to go home.

Eustachian Tube Dysfunction (ETD)

If you talk to someone with chronic ETD, I think they would rather have an STD. At least an STD is curable in most cases. How can something so small cause so much angst? Eustachian tube issues are clearly at the top of the list for postings on WebMD Ear, Nose, and Throat Board. This is an unusual long Blog posting, but this was required in order to cover the full gamete of this disorder.

Dysfunctional Eustachian tubes can cause a variety of annoying symptoms, depending on the type. If the normally-closed tubes will not open normally, the patient will experience ear fullness, popping/crackling, hearing loss (mild), and even temporary tinnitus (ringing). Another less-common type of Eustachian tube dysfunction is where the e-tubes are locked in the "open" position, called a Patulous Eustachian Tube (PET). People with PET often hear their own voices (autophony) or echoes, and of course, they also complain of annoying ear fullness.

The function of the Eustachian Tubes

The two e-tubes (one for each ear) are only about 35mm (1.3 inches) long and runs from the middle ear space (the area on the other side of the eardrum that houses those three tiny ear bones) to the back of the throat (nasopharynx). Adult e-tubes are not only short, but they are tiny, less than a 1/10 of an inch, with a triangular lumen of only about 2-3 mm. The e-tubes of an infant or young child are about half as long, less efficient, and much more capable of becoming dysfunctional. Some people are just born with unusually small Eustachian tubes and have recurrent trouble most of their lives.

There are three main functions of the Eustachian tubes: (1) ventilation (aeration) and air pressure regulation in the middle ear space, (2) Drainage of normal middle ear fluids, and (3) preventing fluids form the nose/throat area from entering the middle ear.

The e-tubes are normally closed (collapsed) but they are required to have repeated openings in order to regulate middle ear pressure. The e-tubes will open when you swallow, yawn, or talk/vocalize. In children, the e-tubes open and equalize pressure with crying. When you come down the mountains in a car or descend in an airplane, you may feel your ears clog and then "pop" (hopefully). These are your Eustachian tubes properly working. Sudden loud noises are capable of causing severe pressure in the ears, an open Eustachian tubes help limit potential ear damage.

The tiny bones in the middle ear space are bathed and lubricated by special bodily fluids which are supposed to drain through the Eustachian tubes into the back of the throat. The cilliary action, special muscles, and gravity-drainage help keep nose and throat secretions from going back up into the middle ear.

Causes of ETD

Perhaps the most common cause of a blocked or compromised Eustachian tube would be the upper respiratory infection (the common cold). The lining of the e-tubes is really the same tissue as the inside of your nose. If your nose swells and gets stuffy with a cold, then your e-tubes can have a similar swelling response. Additionally, when you blow your nose forcibly, you can inadvertently cause air to go up the e-tubes into the middle ear space, resulting in some instant ear fullness. A common complication of colds is post-nasal drainage, occasionally the result of sinusitis. When you are supine, this drainage will flow down the back of the throat where the e-tubes exit, causing inflammation and swelling. In children, the e-tubes exit near the location of the adenoids. The adenoids are lymph tissue that often enlarges when infected or inflamed causing the e-tubes to clog. Chronically enlarged adenoids, especially in children, can cause mouth-breathing, snoring, or a nasal quality to the voice.

Dysfunctional Eustachian tubes (and enlarged adenoids) are a major contributing factor for middle ear infections in children. In younger children, the e-tubes are more horizontal making drainage more challenging. By age six, the neck will sufficiently elongate, improving the "plumbing and ventilation". Additionally, children are more prone to catching colds, averaging about six to nine per year. Children in day-care tend to get even more.

Another cause of ETD can be allergies. Like colds, allergies can cause tissue swelling that can compromise the normal function of the e-tubes. Colds typically last a week or so, but allergies can last year-round in some people.

People who smoke, or are exposed to secondary smoke are more prone to ETD. Smoking can damage the cilia in the e-tubes and interfere with the normal drainage of middle ear fluid.

E-tubes can also become compromised with altitude changes, such as driving in the mountains or even fast moving elevators in tall buildings, scuba diving/snorkeling/diving deep in pools, or with air travel. These events can be especially contributory when the person has a cold or allergies.

How ETD is diagnosed

ETD is diagnosed based on the usual symptoms and certain physical examination findings. During an otoscopic examination, a medical provider may notice that the eardrums are sucked inward (retracted) because the Eustachian tubes are not equalizing pressure. Using a small bulb syringe attached to the otoscope, the clinician can observe movements of the eardrum when positive air pressure is applied. A normal eardrum with air in the middle ear space will move in and out easily. If there is middle ear fluid (effusion) or increased/decreased pressure in the middle ear space, the eardrum will remain immobile. An electronic device used in many offices called a tympanogram can measure eardrum movement and these pressure variations. There are other special tests that the ENT can perform to further evaluate the e-tube appearance or function, if the diagnosis is in question.

How ETD is medically treated

Leave it alone. Most cases of simple ETD caused by a cold, or changes in altitude will self-resolve in time without any specific treatments, however, it is rarely possible to predict when full recovery might happen. Since colds typically last about a week, most people are back to normal in a week or so. So, it could be a few days…a few weeks…or, unfortunately, it could be months or years in severe cases, depending on the underlying causes.

Swallow and chew. ETD is improved by swallowing, chewing gum, drinking, or yawning. (Reading an extensive blog article about ETD can be boring, causing you to yawn, and thus improve your symptoms!).

Self-Inflation. Doing a gentle Valsalva maneuver – Take a deep breath, hold your nose and mouth closed, and try to force air up the Eustachian tubes by blowing. If you feel a "pop", then it worked. Don’t blow too forcibly or you can make it worse, however.

Decongestants. Although controversial, many clinicians will recommend decongestants, either orally or nasally, to help open the e-tubes. This may or may not help. Assuming you can medically-use this type of medication, it is worth a try for a few days.

Nasal Corticosteroids. Steroids (No, not the bad types) relieve tissue inflammation, one of the major causes of ETD. There are several types, available only by prescription, they can be tried if ETD persists. They may be especially helpful if you have allergies.

Antihistamines. If you have middle ear fluid (effusion), antihistamines are not usually recommended. However, if you do have allergies, antihistamines may reduce the amount of rhinorrhea (runny nose) and post-nasal drainage that may be contributory to ETD.

A few words about Airplane Ears. In children, have them suck on a bottle or pacifier. If babies are crying, this can actually help the ears to clear. For older kids, have them suck on a juice box – squeeze on those little juice box straws and make them work a bit to get the juice out. It is not a good idea to fly when you or your children are very congested with a bad cold, if this can be avoided.

Surgical Treatment of ETD – for Chronic or Severe Cases

In cases where ETD does not self-resolve or respond to medical interventions, the person is usually referred to a good ENT. Once the diagnosis is confirmed, either by diagnostic tests or direct visualization of the structure with a rhinoscopy (a fiberoptic, video device), various treatments may be suggested, including these two surgical approaches:

Myringotomy. A tiny slit can be made in the eardrum to aspirate any middle ear fluid and to allow a temporary ventilation portal into the middle ear space. This little slit will usually heal in only a few days, but the fluid and pressure may re-accumulate.

Pressure Equalization Tubes. Instead of allowing the myringotomy to heal, a tiny plastic or metal tube can be inserted into the slit to keep the portal open. This usually will provide relief for 6-12 months, even longer. Both the myringotomy and PET can be done in the office with topical anesthesia (in adults), but children require a brief general anesthesia.

Treating Patulous Eustachian Tubes (PET)

PET occurs when the Eustachian tubes remain open most of the time, creating some annoying symptoms as hearing one’s own voice, breathing, or echoes. This condition is more common in women, and rarely seen in children. The exact cause of PET is not always clear, but there is an odd association between PET and rapid weight changes, either from rapid dieting to the weight gain of pregnancy. TMJ disorders, and the use of certain medications (like birth control pills) have also been associated with PET.

One unusual treatment of PET (for men or women) is with the use of a special-formulated estrogen nasal spray, to induce swelling and hopefully close the Eustachian tubes. There are many other ENT surgical technique that can be used for severe or persistent cases.

Scared Healthy

Fear can be a great motivator, but using fear in a medical practice requires some discretion. For years, we have some great anti-smoker posters in our office – people with black and missing teeth, lip tumors, etc. The non-smokers liked them; the smokers, not so much. Smokers, although will not usually admit it, are expecting a cancer diagnosis just about any day.

On WebMD’s Ear, Nose, and Throat board, I will get a posting of someone worried about a lump in their neck. If they also mention that they are a smoker (but, trying to stop), I can easily guess at their underlying fear, namely, the Big C. As simple and repetitive as this advise has become, giving up cigarettes is a lot easier than living with the fear of an occult tumor forming somewhere.

There is nothing like a physical examination to get someone’s attention. When I come in to the room, I can pretty much determine if someone is a smoker. How? Smokers smell like cigarettes; their breath, their hair, and their clothing. Sometimes, you can see a pack sticking out of purse or pocket. So, in order to have a more "teachable moment", I don’t really say anything about it….that is, until I listen to their lungs.

I will spend a longer time listening; asking them to take a deep breath, or cough, and then listening some more. I feel their necks and armpit areas for enlarged lymph nodes. I try and get that very concerned, sort-of-worried look on my face

“I suspect you are a smoker. How many packs a day do you smoke?”

“Why? What are you hearing? What are you looking for? I now have their complete attention – the Teachable Moment.

"It is quite obvious by listening to your lungs and examining you that you are a smoker. Can you tell me why you are continuing to smoke in light of the fact that it is going to kill you some day? I want you to stop smoking….TODAY!"

ENT specialists see a lot of people with persistent sore throat. As you might expect, the smokers are thinking "throat cancer". Any ENT that misses this excellent opportunity to motivate people (with a little healthy fear) to stop smoking is not doing their job.

"Do I have throat cancer?"

"Not yet, but I do see evidence of tissue changes that can be early signs of smoking related disease. You have to stop smoking…Today. Or, otherwise I may have to give you some very bad news someday."

In the last nine years or so, I have limited my practice to children and adolescents – young people that are often more willing to change their behaviors than adults. Of course, parents of teenagers may differ on that opinion. Medical professionals do seem to have more of an impact on behavioral changes than parents, sometimes. Children, especially teens, can readily tune out parents when it comes to advice.

The importance of good nutrition should always be addressed on well examinations.

"Do you have any concerns about your child’s nutrition?"

"Why, yes. He refuses to eat any vegetables or fruit." A sly grin appears on the mouth of the 8 year old sitting on the table.

"That’s okay. He doesn’t need to really eat those things anymore. (I have HIS attention). We have some great vegetable and fruit shots. You will need to bring him in twice a week. Bring someone to help hold him because those shots a somewhat painful….we have to put them in the corner of his EYES!"

"Shots in my eyes! No way, Mom. I’ll start eating vegetables and fruit. Tonight!"

Okay. We’ll give you another week or so to see if you will eat them. Your mother can just call me and I will make the arrangements for those injections if you don’t.

Yes, it was a bit tricky, but there are really no rules when it comes to getting kids to do the right thing. I am not happy about scaring them healthy, but you do what you have to do in this unhealthy world.

Studies have proven that kids who refuse to eat, say, green beans, have to really eat them TEN TIMES in order not to be repulsed by them. They first have to tolerate them on their plates. Then, they have to be able to pick them up; touch them. Next, they need to smell them and put one to their lips without gagging. The next step is to get them to eat just one, tiny piece; a microscopic amount. They can wash it down quickly with water or juice if they want. The final steps involve eating just one green bean; then two, then three, etc., to the point where they have been tortured with about ten Bean Encounters. Most children should be able to eat them without complaining (too much) after this time.

Many years ago, I did a physical exam on a man that had so many health problems that he frightened ME. He was about a hundred pound or more overweight, had uncontrolled diabetes, hypertension, arthritis, smoked, drank, had a sedentary job (security guard), ate poorly – lots of salt and sugar, and hasn't exercised since high school. He had a strong family history of heart disease. He was a walking time-bomb and didn’t seem the least bit concerned. So, I sent him a registered letter. The letter listed his serious health problems and my recommendations.

I didn't hear from him for nearly a month. I felt that I must have insulted him with that letter. One day, I got a phone call from him.

He said the Good News was that he was ready to make some serious health care changes. The Bad News was that he was calling from the Coronary Care Unit having survived his first (and hopefully, last) heart attack. There is nothing like being on a heart monitor, tubes coming out of every orifice, oxygen, etc. that sort of scares you into being healthy. It is really too bad that it took a heart attack to (finally) get his attention.

Go the Extra Mile – Maybe Ride a Bike Across the U.S.?

Shawn and I were next door neighbors for many years, and of course, still friends. We used to mow each other's lawns, just for the fun of it. Whoever woke up the soonest on Saturday mowed both lawns. He was always an interesting person. When I spotted some old campaign posters in his garage, he informed me that he once ran for a congressional seat in Nevada. There were pictures of him shaking hands with Richard Nixon and Ronald Reagan in his home office. One day, while I was cleaning my garage, he started juggling a golf ball on one of my golf clubs. He informed me that he attended Stanford University on a golf scholarship. Shawn was full of surprises, and secrets, yet to be revealed.

Shawn took up bike riding in a big way. He and his wife originally planned to take a year off and ride around the world! There was actually a group planning this adventure for the millennium. They eventually decide not to go round the world, but Shawn did decide to ride his bike across the U.S. He tried tagging onto a cross-country trip for Breast Cancer, only to discover that the trip was really intended just for women. Insisting that men get breast cancer, too, he pushed his way into the group. By the time they reached Texas (from California) the women basically chased him away. Apparently, a man riding with a group of women ruined the whole group dynamics.

Not to be disappointed, Shawn decided to ride across the U.S. by himself; totally unsupported except for his credit card. He started up the Sierras, cross the Great Plains, and ended up at the Atlantic Coast about three months later. He claims (and I believe him) that he never walked his bike once. He rode the entire way, between motels and roadside greasy spoons.

As a vegetarian, Shawn said the most difficult part of the trip was getting enough non-meat protein, especially in the Midwest. There are only so many bean meals that a vegetarian man can take, although I really can see how a little gaseousness could help you make it over the Rockies.

Shawn is really an entrepreneur, writer, and motivational speaker with lots of ventures under his skinny belt. When his wife called me last week, I had no idea what he was up to this time. His wife makes the best banana bread on the planet, so I was really hoping this was the reason she called, but no….Shawn was riding across the country again, on his bike. You would really think that his butt would have retained the painful memory of his last trip many years ago.

I had to drive a hundred miles to Lake Tahoe over the weekend and take my grand-daughter to church camp. I was exhausted. I can't imagine doing the trip on a bike, let alone go another 3000 more miles just for the hell of it.

Starting later this month, from San Francisco, Shawn, now in his 40's, is going to cross the country again. This time, he is doing it for a different reason – a project called Extra Mile America. He will be starting in San Francisco on July 21st, riding to 21 cities, ending up in Boston on October 8th in just 80 days. (http://www.extramileamerica.com/). In addition to going those extra miles for himself, he is searching for others who go the extra mile in their own communities. He will be selecting ten recipients and give them each a thousand dollars for their projects. Now, that is what I call an extra mile.

Check out his web site and follow his progress. If you live in any of those cities he will be visiting, or the thousands of small towns and villages in between, try and watch out for him. Don't hit him with your car. Give him some water. Give him some encouragement. Give him some ibuprofen. Give him some (vegetarian) food. Or, give him a big, industrial tube of Preparation H.

"I passionately believe that now is the time when we have to do more…to push harder…to be more creative. Now is the time to rekindle that passion to create our own existence and not let the time dictate what happens to us. If we want more in our lives…Let's create more! Let's decide to go the extra mile!" – Shawn Anderson.

Breeding Lexi - A Brief Update

She didn’t "look" pregnant. She was acting about the same; perhaps not eating as well. We found some blood on the deck where she sleeps, so maybe she miscarried or she wasn’t even pregnant. We did have a successful mating (twice), and the male has a good track record, but we just weren’t sure. So, before changing our entire work schedule, we decided to confirm our dog’s pregnancy.

Unlike human that can just "pee on a stick" for a pregnancy test, canines are a bit more challenging. The veterinarian suggested an ultrasound – a $45 procedure. This was not a bad price considering how much we charge for the same procedure in humans. Next time I need an ultrasound, I am going to the vet myself.

When Lexi was a puppy, we gave her a little stuffed animal as a dog toy. She loved it and carried it all over the house. She even slept with it. It was little monkey. It is not unusual to see her all cuddled up with the funny-looking stuffed animal. I tell this story as a prelude to what we saw on the ultrasound.

Shelties are naturally skeptical about strangers. This was really her first trip to the vet and she was a bit squirrelly. I picked her up and put her on her back in this wedge-shaped apparatus. Surprisingly, she tolerated this and remained quiet and still as the technician smeared lubricating jelly on her tummy. As the vet traced the ultrasound transducer around her abdomen, the first of at least four puppies were revealed. Lexi was indeed, pregnant. She may have more than four, but at this point, that was the estimated count. An x-ray on day 45 will give a final count and prepare us for the big day – day 63 (plus or minus two days). The vet printed a picture for me.

I looked at the picture closely when I came home and was a bit shocked. The head view of one of those puppies looks identical – I kid you not – of that monkey she has been carrying around for the last two years. I sure wish that I could add the picture to this Blog so you can see, too, but the resolution was not that fine to reproduce. You will have to trust me on this "monkey baby". I will definitely post pictures of the puppies when the come at the end of the month.

We have about three more weeks of gestation to go before we see those new little puppies (or monkey-baby). It has been nearly 12 years since we had a litter of these cute little dogs in our home. As I mentioned before, three are promised: I am keeping one, one for my brother, and one for the neighbor that lives down the lane. The 4th puppy will not have any problems finding and "approved" home. As with our previous litter, we carefully interviewed prospective Sheltie owners before parting with them. They all found great homes with loving families.

We all work hard in our jobs and careers. It is these little pleasures of life, like the birth of a litter of puppies that makes life so special.