Surviving the Medical Meltdown (34 page)

External ear infections:
An external ear infection is in the outer canal, on the outside of the eardrum. Although it, too, can cause hearing loss when the canal is swollen, hearing loss is not the predominant feature. These infections just hurt. When you grasp the ear and wiggle it, it causes pain. You can sometimes see redness in the canal, but this is difficult without specialized equipment. These infections occur from bacteria getting into a canal that is moist for prolonged periods. Because swimmers often have water trapped in the canal, or at least the canal is wet from frequent exposure to water, external ear infections are common; hence, the name swimmer’s ear. Although antibiotics are sometimes used in severe cases, the usual treatment is topical. Keep water out. Place Neosporin or bacitracin ointment on a Q-tip and carefully insert into the canal. If the canal is swollen, it may need a cloth wick – a short strip of fabric – with antibiotic ointment on it, pushed gently in farther and farther as the swelling recedes. A diluted vinegar solution – one part white vinegar to fifteen parts water to change the pH – can be used to soak the wick or flush the ear. If flushing the ear, use warm water to avoid giving yourself vertigo. If bad enough, use of antibiotics is warranted.

As a preventative measure, you can buy swimmer’s ear solution in the pharmacy or make your own solution. This can also be used to dry up the infected canal once the very raw surface is calmed down.

HOMEMADE SWIMMER’S EAR SOLUTION

1/4 cup white vinegar

1/4 cup isopropyl alcohol

Combine in a small glass jar with a dropper lid. This will keep indefinitely. After swimming, put 3 to 4 drops in one ear. Let it rest for about 5 minutes, and then turn your head and repeat in the other ear.

It is important to take hearing issues seriously. It is said in medicine that more people commit suicide because of deafness than blindness. Blindness cuts you off from things, but deafness cuts you off from people. Hearing loss is generally caused by three things: genetics, noise exposure, or infection to the inner ear. You can’t choose your parents, but you can choose to protect your hearing from loud noise. I have many ex-military friends who have hearing loss from exploding ordnance or jet noise. One of the common causes of hearing loss is loud music. Then there are saws and loud hair dryers and engine noise. Whenever possible, use ear protection. I know military pilots who wear both ear canal plugs and cranial ear protectors (appropriately called Mickey Mouse ears) over them. And finally, if your child has recurrent ear infections, don’t just accept it. Have it evaluated. Sometimes drainage tubes prevent later hearing loss. Sometimes just a simple course of antibiotics is needed – but not always. When a child complains he can’t hear, believe him. The consequence of being wrong can be a lifetime of isolation from conversation with others.

26
SORE THROATS

M
ost sore throats are viral, and no antibiotic will help. There is a tendency to treat all sore throats with antibiotics, but that is wrong and may make you allergic to an antibiotic you will need later in life.

In general, sore throats accompany colds. Rarely do they occur in isolation. The treatment is generally time, fluids, and a soothing solution or lozenge. Once again I caution you against using Tylenol for pain, given the new thinking about Tylenol’s bad effect on the NMDA receptor in the brain. Instead, gargle with salt water. Simply add a teaspoon or two of salt to a warm glass of water and gargle. Topical sprays, such as Chloraseptic, can also help pain.

High doses of vitamin C can help. I can’t prove this, but as noted in previous chapters, I bumped up my vitamin C dose and it helped me. The recommended daily allowance (RDA) for vitamin C is 65 milligrams a day – an intake level so low it does not saturate the white cells that fight off infection. The first thing white cells do in response to a problem is to suck in vitamin C from the surrounding environment. That’s why I take more as a baseline, and I take at least 1,000 milligrams every hour or two when I am ill.

It also helps to get enough rest. Many young doctors know that
they get sick as they get overworked – because their immune systems are not functioning optimally when the body is sleep deprived.

Some young people have very visible tonsils with pits, and these get filled with dead cells and debris and can become infected. This is one reason for removing tonsils. But tonsils are a line of defense for infection. When I was an overworked, sleep-deprived medical student, I had recurrent sore throats. I would look at my throat in the mirror with a flashlight and see enlarged tonsils that looked like sponges with white junk in the holes. I reasoned that the immune system cannot get into spaces without good blood supply (which is why we drain abscesses). I took a tongue depressor and systematically massaged the tonsils to remove the white debris as it accumulated, and over time my tonsils became invisible and my sore throats went away. I don’t recommend this for everyone, but if you have this problem and can handle the tendency to gag, it does work.

For a sore throat that is persistent, has swelling, has any compromise of airway, or is accompanied by unrelenting fever, seek medical help.

27
ABSCESSES, BOILS, AND ZITS

A
n abscess is a pocket of pus that is walled off from the surrounding tissue. It can be acute or chronic, small or large, deep or superficial. Our bodies take care of small, superficial abscesses all the time, especially in the hand, when it expels a small splinter along with a little wisp of white pus. The most common abscesses we encounter in everyday life are due to a foreign body – like a splinter or a thorn – that penetrates the skin. When a small piece of wood or other material gets under the skin, the body sends white cells to attack this “invader.” In the process these cells die and gel together, giving the characteristic yellowish-white pus. Often the pus pocket and surrounding inflammation are enough to cause the object to become loose under the skin and pushed to the surface. Sometimes, however, the abscess is beyond the body’s capability to deal with. In this case the abscess will become bigger, painful, warm, and often soft in the center due to the pus. Sometimes infection will start to spread, and you will see redness streaking up the skin.
Boil
is a term generally used for abscesses that develop in the buttocks, usually around a clogged hair follicle.

Abscesses are benefited by the following, in order of progressively more aggressive treatment:

1. Warmth
helps stimulate blood flow, which brings in more cells to fight the infection. Moisture helps soften the skin in case a track to the object can be opened. It also makes the skin more permeable for passage of the foreign body or for pus to drain. You can soak in a tub, put the extremity in a warm sink, apply a heating pad over a wrung-out wet washcloth, or simply apply a heating pad.

2. Antibiotics:
In the age of antibiotics, the reason the world still needs surgeons like me is that
antibiotics do not penetrate into an abscess
. All they do is treat the surrounding area and help prevent the spread of infection, but they are only useful in small abscesses; the body itself must spit out the object, or the abscess must drain spontaneously through a small channel, and any antibiotics are used as an addition to (not in place of) the warm soaks.

3. Surgical drainage
is needed for any abscess that is persistent, large, fluctuant (soft in the center, suggesting liquid pus), or accompanied by spreading redness. Usually this means seeking professional help. But sometimes, you may have a localized hot, red, swollen abscess with a very superficial pus pocket that can easily be unroofed and the pus released. Generations of farm wives have drained pus pockets in their kids and husbands by heating a hat pin on the stove to red-hot over a flame, cleansing the abscess, then pricking it with the sterile pin to cause the pus to come out. That technique still works. I have done that at home with my kids and myself. I use alcohol on the skin, but otherwise, all my surgical training doesn’t add much to Grandma’s hot pin idea. (I just happen to have 18-gauge surgical needles at home.) Don’t get lazy with sterilization techniques. Use isopropyl alcohol on the skin and a sterile needle. Sterilize the needle by boiling it for ten minutes, heating it to red-hot, or swabbing it with isopropyl alcohol. Sometimes there is a very thin roof of dead skin over obvious pus. Make the biggest drainage hole you can make – piercing dead tissue doesn’t hurt. Get rid of as much dead tissue as possible. Your patient will let you know when you get into live
skin! If you have a scalpel, this works better for bigger areas. Even surgeons do not usually use anesthetic in these cases because there are no nerve endings in dead skin, and anesthetic doesn’t get into infected tissue well – plus, it hurts more to inject anesthetic than it does to do one quick jab to release the pus.

Once the pus is draining, sit in a tub (if the abscess is in the buttock, for example) to soak the area. Sometimes a 50 percent solution of hydrogen peroxide (equal parts water and hydrogen peroxide) can be used with a bulb syringe or standard hypodermic syringe to irrigate the wound. After draining a large abscess, pack the hole left behind with sterile gauze soaked in a mild soap solution (see sidebar) or in an acetic acid solution (see sidebar). Smaller abscesses are best treated with topical antibiotic gel. Any significant, spreading redness means
head for professional help
. If help is not available after doing all of the previous steps, start clindamycin (300 mg) three times a day and cipro (750 mg) twice a day.

MILD SOAP SOLUTION

3 to 4 drops mild antimicrobial soap (such as Hibiclens) or baby shampoo

1/2 cup water

Slowly stir the soap or shampoo into the water.

ACETIC ACID SOLUTION

1 ounce white vinegar

15 ounces water

Combine and use for treating abscesses and other abrasions.

“Zits” (or pimples) are actually a different kettle of fish. Acne and its variants cause swellings that look a lot like little abscesses, and maybe they are (I never quite learned that in medical school), but they are treated very differently. Generally, surgical drainage is not indicated. My son, in his senior year of medical school – with a little bit of knowledge but not quite enough – decided to do the
hot pin trick to a progressively swelling facial lump. It looked for all the world like a deep abscess, but as he found out, poking at it made it worse. In general, isolated, firm facial swellings larger than the normal pimple need antibiotics (Keflex 500 mg four times a day, tetracycline 250 mg four times a day, or doxycycline 200 mg twice a day, or a combination of Cipro and Clindamycin as described above, until gone) and should not be squeezed, needled, stabbed, or in any way mechanically irritated. Topical treatment with metronidazole gel or clindamycin solution is helpful. Nothing, however, is more useful than a dermatologist or primary care provider who knows about skin and acne.

It is important to note that infections in the facial area drain into the venous system of the brain and can cause serious problems if bacteria seed the veins in the brain. If the infection seeds the cavernous sinus, a complex venous plexus at the base of the brain, it can cause a clot, from which one can die suddenly. As I entered puberty, my physician dad told me about this potential disastrous outcome to encourage me not to pinch pimples. So as other kids were worried about running with scissors, I was worried about dying suddenly of “cavernous sinus thrombosis.”

In summary, don’t “pop zits,” be very attentive to unusual facial swelling, and in the medical meltdown don’t hesitate to use your antibiotic store for anything that you think is a facial infection.

28
EMERGENCY DENTAL CARE

D
entistry is a highly specialized, technologically demanding field, so dental problems must always end up in “the chair.” However, sometimes things happen at 2 a.m. on a Saturday, and you need a plan for the weekend.

Losing a tooth or a piece of a tooth
spontaneously is usually not an emergency unless a tooth breaks in such way as to become painful. That generally means the
dentin
, or inside, of a vital (live) tooth has become exposed to the air. For a fractured and painful tooth, first rinse the area in warm water. (It may be very sensitive to cold.) There are over-the-counter waxy compounds that can be purchased at the pharmacy to temporarily cover the exposed dentin. In the absence of that, clove oil is a dental anesthetic. Soak a cotton ball in the oil of cloves and apply to the broken tooth. Ibuprofen (Motrin) is short acting but one of the best non-narcotic pain medicines.

Dental abscesses
are one of the most painful of nature’s plagues on humanity. My father was a physician and a research dentist who years ago helped develop the first fluoride toothpaste. (Unfortunately,
although a professional student, he never attended law school and didn’t understand patents well, so he lost out and I continue to work.) Ironically, I inherited my mother’s strangely bad teeth that rot from within. I literally have had root canals for abscesses in every tooth in my head. I finally did the last five prophylactically because I got so tired of being in pain. And it solved the problem, but trust me when I tell you that
nothing
hurts like a bad tooth abscess – not even childbirth, and I’ve had both. Over the years I was on a first-name basis with endodontists all over the country, wherever I lived, and in the Navy. When I developed my last classic dental abscess, I woke up with some pain that got gradually worse in the morning. I called the endodontist for an appointment at 4 p.m. At 1 p.m., I showed up in the office, and when the secretary asked me why, I told her, “I have no place I can go like this. I’ll just sit here, and maybe he can numb me up and let me wait. If not, I’ll just sit without moving.”