Surviving the Medical Meltdown (33 page)

good posture in bed

bad posture in bed

I could make a living off people who work in front of a computer and the neck pain they suffer. Get your keyboard up so that, when you’re keyboarding, your arms are at 90 degrees elbow flexion and you are generally looking straight ahead or up a little. The worst ergonomic thing ever invented was that little pullout keyboard that is nearly on your lap, forcing you to look down all day. Don’t use those. If necessary, put those out-of-date books under your laptop to elevate it.

Upper back pain:
Less commonly, someone will reach for an object above chest level and experience a sudden sharp pain in the upper back. You can do the self-treatments outlined earlier, but if this pain is not resolved in twenty-four hours, consider a visit to the chiropractor. I’ve found chiropractic manipulation is extremely helpful in solving this problem in short order. Unfortunately, if the pain sets in over weeks, it is then hard to treat successfully to resolution.

In each of my examination rooms I have a framed copy on the wall of my rules for a healthy back.

DR. HIEB’S RULES FOR A HEALTHY BACK

1. Don’t smoke.
Smoking kills bone cells and decreases oxygen to the disks.

2. Stay thin.
Every extra pound in abdominal weight translates to several pounds of added pressure to disks.

3. Choose to be happy.
Victor Frankl learned in Auschwitz that we cannot always choose what happens to us but we can choose how we react. It does not help to focus on things we cannot change. Sometimes we have to live with arthritic back pain. I cannot sit on the floor with my children the way I could when I was younger. Some back pain is a fact of life, and rather than become debilitated, we should do what we can to be fulfilled in life and to reach out to others.

4. Be physically fit.
Core strength is key to improving and avoiding back pain.

5. Use good back mechanics.
Avoid twisting, bending, and leaning.

6. Think ergonomically.
Use your head, not your back. Find back-safe ways of doing the job.

7. Avoid reinjury.
When that air conditioner you just bought starts to fall off the truck – ya gotta let it go. Choose to save your back, not the replaceable object.

24
FOOT PAIN

F
oot pain is either focal (involving one discrete spot), in a bigger area over the mid-foot, or localized to the arch, the heel, or the “ball” of the foot. A lot of foot pain is due to shoe wear, so you should not try to squeeze your feet into too-narrow shoes. The best shoes for your feet have a wide toe box and good crepe soles and are built for the activity you are doing. Don’t play tennis in running shoes, and vice versa. As you get older, your feet need more padding; avoid standing barefoot, and wear well-padded shoes as much as possible. Another thing, which is not talked about in the literature but which is very clear from my practice, is the association of hormone loss with foot pain. When women go through menopause, they commonly develop foot pain – stiffness in the morning and pain with prolonged standing. This usually resolves with appropriate hormone therapy.

Focal pain
is pain that is especially localized under the balls of the feet and is usually due to aging and loss of fat padding. Insoles may help this, or you can place a pad just behind the balls of the feet to take the pressure off the bony prominences under the ball of the foot. Some local pain is due to corns or calluses that become enlarged
and thickened and become pressure points. You can trim these with a toenail clipper (or scalpel blade, to be traditional). Check for abnormal shoe pressure that may be causing this.

Heel pain
that is under the heel proper (calcaneal bursitis) or at the junction of the heel and the arch (plantar fasciitis) can be a nuisance and may take time to resolve. Treatment consists of anti-inflammatories, weight loss if obese, and plastic heel cups that squeeze the heel while walking. This effectively gives you more heel padding.

Mid-arch pain
is in the mid-foot and is worse in the morning, gets better after a little walking, but gets worse again after a lot of walking. It is classic arthritis pain. The treatment includes good shoes, avoiding going barefoot, choosing a sport other than walking or running for exercise, and taking Naproxen or other anti-inflammatory as needed.

Toe pain:
In the absence of deformity, pain in the toes can be pressure from shoe wear, commonly called a “Morton’s neuroma.” Morton’s neuroma is compression of the nerves that run between the toes, due to tight shoes and an inflamed or enlarged nerve. You may experience sharp knifelike or electrical-shock pain into the toes with walking that resolves when you take off your shoes. Or (less commonly) this condition can give you an achy, deep pain that radiates up to the back of your knee. Although sometimes a neuroma leads to surgery, home treatment is wider shoes and anti-inflammatories, such as Naproxen.

Bunion:
A bunion is an enlargement of the soft tissue and bone around the joint between the toe and the foot bone (metatarsal). It is often associated with a deformity of the toe that drifts into a position crowding or overlying the second toe. Most bunions occur at the great toe junction, but lesser bunions can occur on the outside of the foot over the little toe junction. Pain is due to stretching of the soft tissues and to inflammation. So, again, the treatment is well-fitting, wide-toe-box
shoes, and anti-inflammatories. Although foot doctors don’t generally believe in them, I have found from personal experience that spacers placed between the great and second toes do help the pain. I never had a bunion in my life, having grown up mostly barefoot, and seldom wearing high-fashion, pointy-toed shoes. But at age fifty-five, when I became president of a national organization, I found myself wearing a suit and “pumps” frequently at meetings. After a weekend of meetings, I would have pain and swelling over my right great toe joint. I saw my friendly podiatrist, who agreed that it was a bunion. Not wanting surgery, I took an anti-inflammatory and put a spacer between my toes that took the stretching off the soft tissues that were inflamed. I avoided any dressy shoes for six weeks. At the end of that time, my pain was resolved.

There are two types of specialists who deal with foot and ankle problems – orthopaedic fellowship–trained foot and ankle surgeons, and podiatrists. Foot and ankle surgeons have one to two more years of surgical training after the five-year orthopaedic residency and four years of medical school. They are few and far between, often in university settings, and are fully involved in the government system. Podiatrists have four to five years of training and were traditionally cash based but, sadly, have begun to drink the Obamacare Kool-Aid. I think most podiatrists still do some cash practice and are more likely to be available in a meltdown. For the uncomplicated foot and ankle problems that you are most likely to develop, podiatrists generally do a very fine job and are much easier to access.

25
EAR INFECTIONS

O
ne of my most memorable days as an intern was the day I cured “deafness.” I was on call on ear, nose, and throat – properly known as
otorhinolaryngology
but generally called ENT. I was sitting in the on-call room with the third-year ENT resident when the phone rang. He answered, listened for a while, then asked, “What do the eardrums look like?” After hearing the caller’s response, he said, “I think this sounds like an intern-to-intern problem; hold on,” and he handed the phone to me. My fellow intern told me about a patient who had come to the ER complaining of sudden-onset deafness. He was fine the night before, but that morning suddenly could not hear. When I asked the intern the same question the resident had – “What do the eardrums look like?” – I realized why the phone was handed to me. My fellow intern (this wasn’t perhaps his brightest moment) said to me in all seriousness, “I don’t know. I can’t see the eardrums because of all the wax.” After looking disgustedly at the ENT resident, who was, by then, laughing pretty hard, I hung up, went to the ER, cleaned out the gentleman’s ears, and voilà! He could hear again! The practice of medicine isn’t always complicated; we just try to make it that way.

Earwax:
Earwax is not a problem for everyone. The amount of wax production and the size and shape of the canal are genetically determined, so some people have more buildup than others. As in my internship story, one of the major problems is blockage of the external ear canal and thus blockage of sound hitting the tympanic membrane (eardrum). Q-tips, napkin corners, and other such things can actually push earwax deeper into the ear. But I still clean my wet ears with a soft Q-tip, and I doubt most people will give that up. So what do we do when we feel the ear canal is blocked with wax? Before I have a physician look in my ear, I mix equal parts of hydrogen peroxide and quite warm water. The resulting solution should be about body temperature – tepid but not hot to the touch. If you use cold water to irrigate the ear canal, you will induce severe vertigo (dizziness and room spinning). My fellow students and I did this for a test in medical school, and it was not pleasant – let me assure you. Use a blue bulb syringe and put the solution into the ear so you feel it bubbling. Let it sit for several minutes with you on your side, ear up. After that, use the rest of the solution to gently irrigate the canal, then tilt the ear down so any debris can drain into the sink or basin. If this doesn’t work, you will need a physician. Do not use a bobby pin or any firm object in the ear canal. This can scratch the canal and lead to infection or perforate the eardrum.

Other foreign bodies in the ear
are usually the result of children putting things such as dried beans in the ear. But occasionally insects will make their way into the outer ear canal. I keep a small surgical grasper called a
pituitary rongeur
for removing small things from small places. If the object is prominent, you can grab it with tweezers.
But do not scratch the ear canal wall in the attempt
. Small insects can be felt and heard by the victim, and they often can be flushed out with the same technique used for removing wax. In this case, you can just use warm water and tilt the ear to the sink. In inner cities the most common foreign body in the ear is a cockroach. Although through eons, the
cockroach has adapted to all sorts of environmental challenges, it has never evolved enough to be able to back up. So if a cockroach crawls into your ear while you are sleeping, it has no way to go but inward. As an intern I became somewhat proficient at removing these with the pituitary rongeur – rather like fighting a fifteen-pound bass on a six-pound test line. If this happens to you with either a cockroach, a June bug (a more common scenario in the Midwest), or a similar bug, and you can reach it easily with tweezers, you can try getting it out. But remember: don’t scratch the ear canal. If unsuccessful, you may have to seek medical attention for the proper tools and fishing skill.

Itching ears
are usually due to dry skin. This often happens in the winter. If you are prone to eczema, itching ears may be a manifestation of sensitive allergy-prone skin. This is usually treated simply by swabbing the ear with a Q-tip dipped in a little 1 percent hydrocortisone (HC) cream. Don’t do this frequently. Frequent use of steroid cream can thin the skin. I probably do this three to four days in a row once or twice a year at the most. It is also important not to let your ears stay moist. I know we are told not to put anything smaller than our elbows into our ears, but if people actually followed that advice, why are Q-tips still sold? Being curious, I did an informal poll of my medical colleagues and found that they
all
use Q-tips in their ears. So why do we persist in telling patients
not
to use Q-tips when we should be telling them
how
to use them? I dry my ears with Q-tips. I buy soft, good-quality ones, and I just don’t try to push too deeply – just as far as the tip goes comfortably and without scratching the wall of the canal. If you are prone to trapping water in the ear after showering or swimming, use a swimmer’s ear solution regularly. You can buy these in drugstores or make your own (see below).

To simplify the issue of ear infections, there are two general categories – external ear infections and internal ear infections. External ear infections involve the outer canal and can often be treated with topical medications. Internal ear infections are infections behind the eardrum and cannot be reached by topical treatment.

Internal ear infections
are more complicated and generally require antibiotics. They will sometimes resolve on their own because some are viral. But if an untreated bacterial ear infection persists, it may perforate the eardrum and cause hearing loss – temporary or permanent. An internal ear infection may cause a sense of fluid or a “sloshing” sound in the ear. Some hearing loss is common. It may occur after a cold or allergy that causes the Eustacian tube (drainage tube from the ear) to be plugged. In this instance, fluid backs up into the middle ear and may bulge out the eardrum. This fluid then gets colonized with bacteria. Generally a Z-Pak (or a ten-day course of erythromycin, or penicillin if you are not allergic) will take care of the problem.