Smoking. Be smarter than Einstein! He was noted by Walter Cronkite to pick up cigarette butts from the Princeton campus and smoke them in his pipe; his doctor had forbidden him to smoke. Nicotine works on the pleasure centers of the brain, and rats will starve to death pressing a pedal for it. I do not judge a person for smoking, but our bodies do. Nonsmokers usually do not recognize that nicotine is a smokers most reliable friend and lover, and when it comes right down to it, they would rather die or lose their spouse than give up nicotine. It is the most addictive and cancer-causing substances known. If a one pack per day smoker took an injection of a weeks worth of nicotine it would kill him instantly. Ask your pharmacist for the product information on nicorette inhaler - four cartridges is enough to kill half those who ingest them [the lethal dose 50]. Shoot it in your veins it feels as good as heroin or amphetamine.

Smoking is the greatest cause of death and disability in America. 440,000 people die of smoking related problems every year in this country. That is more than twice the toll of alcohol, and many times the toll of accidents, AIDS, violence and other drugs of abuse put together. 40,000 deaths a year are nonsmokers exposed to others smoke; 6,200 are children. Smoking is the most frequent reason for lost time from work. Before smoking became popular during World War I, lung cancer and heart disease were exceedingly rare diseases; of course, otherwise healthy people were dying of infectious diseases. Smoking has been proven to cause cancer in the mouth, esophageal, stomach, lung, and bladder, as well as greatly increase the risk of heart attack [MI], stroke, cataracts, worsening arterial disease in the legs, raising blood pressure, contributing to impotence, and increasing the risk for bronchitis and pneumonia. The only reason people would pay to acquire all this disease is that nicotine is twice as addicting as cocaine, alcohol and caffeine. Breast cancer, which occurs in one out of eight women, is now less common than lung cancer in women, specifically because of their smoking habits over the last 30 years. People often say "I do not smoke that much, doc." But a large study has shown that smoking even 4 cigarettes a day places a person at risk for MI and strokes by making the blood more sticky and likely to clot. Half of MI victims just drop dead; thetas personally painless, but not for the bereaved family. Others do fine on daily medicines, or require open heart operations. Having a stroke means a brain blood clot instantly turning a walking, talking person to someone who lays in bed soiling themselves, not being able to move half their body and not being able to call for help. I have had a patient have an MI on one cigarette a day, we have seen 19 and 25 year olds getting strokes and MIs. I had a lung cancer patient who stopped more than 20 years before diagnosis. Smokers have a 70% greater mortality rate than nonsmokers. Another way to express this is that the life expectancy of a 30 year old two pack per day smoker is 8 years shorter than a 30 year old nonsmoker. Even a 65 year old who stops smoking will live on average 5.5 years longer than he would have if he had kept on smoking. Since every other smoker dies of the habit, in a pair of smokers that quits, one gets 11 years of life back. Even 85 year olds are proven to benefit from quitting. George Burns was the exception, not the rule, and he died at age 100, having survived a heart operation. Many other famous people have made public pleas, as they died of emphysema and cancer, urging people to stop smoking, among them, Yule Brenner, Alec Guiness, Clark Gable, Humphrey Bogart, John Wayne, and Chuck Connors. Victor Crawford, who set up the Maryland Distinguished Scholar Program, was a tobacco lobbyist until his diagnosis of throat cancer. He then fought against smoking until his death in 3/96.

Smoking while pregnant can result in low birth weight babies that are sickly and more likely to have crossed eyes. Stopping smoking for good is especially important for your children, who are 4 times more likely to smoke if a parent smokes, and almost all smokers began smoking in their teens. People who smoke are paying money to acquire hideous disease. I believe that if Martin Luther King were alive he would be fighting against smoking. He protested the Viet Nam War; our citizens are dying from tobacco at 90 times the rate that we lost soldiers there. Because they are more likely to smoke, Hispanics and African Americans are particularly slain by the habit; we should all know that our hard earned tobacco money cannot go for food, housing, or education; rather it goes to rich white Southerners that are happy to kill us with their products regardless of race, color or creed. Interestingly, they do aim advertisements for cigarettes and alcohol at minority groups, as well as children to replace the dying.

The tide turned and is now stuck. Since the sixties when the Surgeon Generals original report on the health risks of smoking, people who quit easily, did, or did not start because of negative social stigma. The rates have dropped from 50 to 25% and have leveled off. This means remaining smokers need all the help they can get, especially toward making quitting a positive experience. The sooner one quits, the better. A single cigarette can cause relapse to ones old habit, and there is evidence that ex-smokers have permanent changes in their brains that would happily welcome nicotine back, forever. Several attempts are frequently necessary to achieve permanent smoking cessation. You can avoid any weight gain by exercising aerobically 20 minutes daily or more, especially 20 minutes twice daily. You can take control of your lives and turn away from destructive habits and toward healthy growthful habits. Every cessation attempt should be taken seriously, since stopping smoking can save your life. Family members that smoke are more likely to quit smoking if they all stop smoking at the same time, get all the paraphernalia out of the house, discuss the health risks and make a commitment to never smoking again. The earlier one smokes or chews after rising, the more one is addicted. Some people even wake up and smoke. Fewer cigarettes simply means a lower level of addiction. There is no minimum. Congratulate yourself on the decision to stop smoking, because your body begins healing itself immediately, ending the excess risk of bronchitis in 6 weeks, MI by a year, cancer by 10 years. I am happy to prescribe bupropion, (Welbutrin, Zyban), which is the only treatment proven to work at one year better than placebo, and is only contraindicated when there is a history of seizures.

Drinking: Please read this section too; it could save a friends life, since the most important symptom is denying the problem - both the alcoholic, and relatives [called enabling and co-dependency]. Alcoholism affects 18 million people in the U.S., and the tens of millions of people that know them. It is often progressive and fatal; and is characterized by impaired control over drinking, preoccupation with alcohol, drinking despite adverse consequences of alcohol, distorted thinking, especially denial, and continuous or intermittent symptoms. How much alcohol is too much? Some alcoholics get drunk on a half glass of wine or beer. Can one be alcoholic if one only drinks beer or wine? Sure. Alcohol kills brain cells and depresses and impairs judgment; no wonder it is involved in at least 50% of fatal vehicle accidents, two out of three murders and one third of suicides. While the biggest killer is cigarettes [440,000 a year in the U.S.], alcohol follows with about 200,000. Many screening questionnaires have been developed for alcoholism; here are two:

CAGE:

Any affirmative answer is concerning for alcoholism; two makes it likely and three very likely.

MAST [ Michigan alcohol screening test]:

Alcoholism is indicated by a score of five or more.

Personally, I think any positive score is worrisome for possible alcoholism and the person should abstain from alcohol, since having scored 2 for drunk driving, someone could kill me next time they are on the road drunk. People who score 5 or more should never drink and should be in counseling and or Alcoholics Anonymous on a sometimes daily basis. The MAST test should not discourage anyone from going to AA by making them think their score makes them alcoholic. That we should all go to see what it is like is reflected in my med schools requirement that each student attend a couple of sessions.

Medical problems from drinking: $136 billion worth yearly in trauma, violence, acute intoxication leading to coma, damage to limb nerves, liver disease which can cause coma and inability to stop bleeding, bleeding ulcers, fatal inflammation of the pancreas, chronic diarrhea, hemorrhoids and their equivalent in the esophagus, heart rhythm problems, fatal enlargement of the heart, high blood pressure, impotence, osteoporosis, anemia, low birth weight and infant mental retardation. Alcohol also interacts with medications, enhancing the depressant effects of sleeping pills and antidepressants, decreasing the effectiveness of dilantin for seizures, and increasing the likelihood of low blood sugar on pills for diabetes.

At least one quarter of sons of alcoholic fathers become alcoholic. But alcoholics often come from stable family situations and are previously healthy. Twice as many identical twins raised separately are both alcoholic than non-identical twins, suggesting some inheritable tendency toward alcoholism.

Alcohol tends to keep a person from dreaming while asleep which means awakening unrefreshed; a radio announcer in the 1950s was kept from sleeping and dreaming for 200 hours [at his request] and became quite paranoid, until he got some rest. This generalized poisoning of the brains recuperative cycles plays a strong role in alcohol withdrawal seizures and hallucinations. People often drink because they are depressed or hopeless, but alcohol is a strong depressant and worsens the persons feelings. It does relieve anxiety, but there are nonaddicting medicines for this as well as counseling. A bottle is not an interactive resource like counseling.

The diagnosis of alcoholism carries a stigma, but the fact is that our brains must respond to something; if a person craves alcohol or scores high on the MAST questionnaire it is better to accept the diagnosis and not drink than to ignore it and die in a flaming mass of metal, glass and gasoline. Feeling a need for alcohol and dreading going without is part of addiction, not a personal flaw. I have been telling my sons, you are responsible for your actions and your health. People can take control and actively recover.

Alcoholics Anonymous 410-433-4843 5438 York Road, central office. Also, there is a new method of staying away from alcohol called SMART, self-management and recovery training developed by Harvard doctors that is not spiritually oriented, 1-216-292-0220.

As for the occasional study that purports a benefit to wine or beer, please note that these are always retrospective studies funded by the industry. No one could do a double-blind, randomized, prospective study on alcohol compared to water without cutting a hole through the abdominal wall and inserting a tube to bypass the taste buds. One expects lots of hope by the population and the rich people selling the stuff that there is a benefit to an addicting neurotoxin. I expect no benefit and much harm. The latter is already proven. The benefit in red wine or beer is going to be in the grapes or the barley or hops, if anywhere. This section is written in memory of a 35 year old alcoholic whom I sent home from the hospital to die. He had no liver left, hence, no ability to clot his blood. I told him that within a few weeks his esophageal varices [like hemorrhoids in the food tube] would burst and that nothing could stop his entire blood volume from then being pumped out his mouth onto his bedroom floor. Two weeks, it turned out.

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Drugs: do not expect narcotics out of me without good cause! Everyone responds to drugs. The poppy plant luckily or cleverly learned to imitate the endorphins that are released in the fluid spaces of our brains upon exercise and pleasurable experiences. Throughout history people have systematically sought out the substances in nature that alter our physical or mental state. Today, many people use drugs. You might even worry that I do. The reason I do not use drugs is that my body is a temple and I need every last brain cell, my family needs me sharp and so do you. Most drugs are neurotoxins - they specifically poison brain cells.

This is true of marijuana, despite what you have heard in the emotional public debate about it. Legalize it, and we will see much more cancer from it, and obstructive lung disease, and maybe brain damage, since it is mostly smoked to carefully titrate the dose; the dose is harder to control if eating it. Legalization may reduce the killing of innocents in gangs gun battles, but we should think very carefully about it. Do we want to pay to support millions of pot heads who just have to have their drug and cannot seem to do anything else, like work? As Surgeon General, I would insist on negative random drug, alcohol and nicotine screening as a prerequisite for any kind of public assistance. What man wants to have big breasts because of his pot habit? The saddest story I have heard about pot is a grower who simply wanted to watch his plants grow and watch the smoke curl up from his joint. His girl friend was pregnant with his child. He was going to be too stoned, and his priorities too messed up, to be there and adequately parent his child.

Lets consider cocaine next. Even if the first high feels like a whole body orgasm, users fruitlessly try to attain that high again, using more and more, maybe having a seizure, maybe a stroke, maybe dying from cardiac arrest. Just like smoking tobacco, that hideous pressure on your chest as your life ends is self-inflicted. But you do not know that it is coming soon, with a purer batch - -you tried to use the same amount of powder. There is now evidence that smoking tobacco increases the craving for cocaine, so users must quit both at the same time, and that baclofen can be given to reduce the craving.

Heroin is next. Smoked, sniffed and shot - before trying it you should see Drug Store Cowboy with Mat Dillon. Opiates like heroin can stop your breathing. They do not mention that in the song that goes, ÒI want to get you low... a million poppies are gonna make you sleep, a million miles below our feet.Ó More like just six feet. Heroin abusers shoot through infected arms, dying of rampant infection, ruining heart valves, and you and I pay for the valve surgeries. One guy told me he had gotten Òpink bloodÓ in a neck artery instead of a vein, and survived shooting directly into his brain. How many did not, I wonder? Before you consider using, maybe you should wonder, which loved ones will carry off your rotting corpse when you die of it? A guy complained he needed to withdraw from heroin in the hospital on benzodiazepenes [which I try to avoid prescribing too]; it turned out there was only strychnine in his blood - for which he had paid good money. People also buy methadone that addicts spit back into a cup on the street outside their clinic. Opiate abusers whine and manipulate. When I check out a suspicious story, usually a person is getting a few addicting pills from at least a dozen doctors, perhaps at as many pharmacies. Synthetic heroins have produced frozen people because of MTP in it destroying the same neurons lost in Parkinsons disease.

Regarding LSD: the diethyl derivative of an amine of the ergot fungus, which can rot your legs off, and caused the deliriums of the Salem witch trials because of rye bread contamination. Who needs bad trips or flashbacks? Would not it be better to get an A in math instead, and eventually a job? If as a high-schooler you think it is better than sex, your friends do it, you have a pure supply, and you hate your parents anyway, so why be good, then consider that you have got no perspective at fifteen, I did not either, your friends are not as bright as you, and they are getting duller fast on drugs, teenage sex is the blind leading the blind, so anything is better. You might not OD, but how can you be sure of the quality and lack of contaminants? If you are doing it to nuke the parents, it is a hurtful expression of your anger, - - it hurts you. We do not really have time to waste being high. Most of us have made commitments to others and being drunk or high makes us worse than useless to the ones we love, including ourselves. We can hurt or kill ourselves or others. When we are teens, we think we have a right to experiment, and that we are invincible. Often teens do not believe there could be permanent brain damage from using pot, for instance, but they will readily label the real pot-heads in their class. How did the pot users get so dumb? In 3 to 7 years they will be expected to have a marketable skill, and likely college debts to pay off. I have seen employment denied to physicians with pot in their urine. So it does not really matter what you or I think, but rather, what employers and the government thinks about drug use. We need to participate in society to succeed, and that participation is thwarted by drugs. It is a limit society sets, appropriately: it does not want you if you use drugs. It does not want you driving, teaching, piloting or doctoring. Honestly, it is unlikely you will do time in jail for drug abuse. But your body is a temple too, and no matter what the hype, drugs do surely do something to your brain, heart and lungs. Surely the risks, even if unproven or unknown, outweigh the benefits. Better to get high running, reading, parenting, singing, playing or having conjugal privileges (please kids, do not look that up). Better to love yourself, and your significant other, than a poisonous powder. And while I am at it, wear ear plugs at concerts to protect your hearing. I like to play it, but I sure do not like the racket. [from the song, I am an Adult Now]. Narcotics Anonymous: 410-947-8028

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I need an antibiotic, Doc. The Sun featured an article on increasing antibiotic resistance in the world and hence the potential for common treatable diseases to become untreatable killers again. Then a woman wrote the editor that her doctor had always given her antibiotics at the drop of a hat, so her body had become immune to them and she needed them to nip an infection in the bud, and what was all the fuss about. So John Bartlett, M.D., head of the Infectious Disease Department at Johns Hopkins Hospital wrote in to say that infections should be treated only based on culture results, and that most empiric antibiotic treatment of viral and allergic bronchial, throat and sinus conditions was worse than useless because of the chance of infectious diarrhea and sometimes fatal allergic reactions. I thought that would lay my case to rest, the conservative view, that is, that antibiotics should be used cautiously and specifically. So I repeated the above op-ed letters to a patient who said, yeah, but I think I would like an antibiotic. I did not scream like I wanted to. Lets go over some basics. We are now in the antibiotic era. Before antibiotics, people did die of infectious disease in very large numbers. Some people still do, like those who refused the pneumonia vaccine, or just have to shoot intravenous drugs, because despite the best antibiotics and hospital therapy, the infections overwhelm the patient. And be aware that in the world, every 90 seconds a child died somewhere of malaria, not to mention the more common deaths from diarrhea and dehydration, which are all easily treated in this country. In 1996 in Baltimore, there was a 2 year old who developed an infection that went through his blood and ate a hole in his arm bone because it was so resistant to antibiotics. He spent 2 months in the hospital on IV antibiotics, and his bones finally began to heal. You do not want this to happen to you or your child, but it will commonplace if fatigued doctors continue to cough up useless prescriptions to demanding patients. People were invented before antibiotics, doctors, and surgeons. Our ancestors suffered along well enough that 6 billion of us are here today. This means without antibiotics, humanity would survive. We have an immune system that is built to fight off whatever might evolve in numerous and effective rapidly evolving ways. One valid question is, will the overuse of antibiotics kill us all? As we spray crops, insects become more and more invulnerable, and more numerous because we have killed their natural predators or benign cousins that competed for food. A perfect analogy exists in our own bodies. Antibiotics are available over the counter in many countries. These are used so often, for so little excuse, that they are ineffective and these are the first countries where resistant gonorrhea and syphilis arose. That process took decades to reach us, but is accelerating because of the frequency with which vacationing people feel compelled to share body fluids with people throughout the world. It does not help that financially strapped Health Departments are often not obtaining cultures of infections before treatment, but rather giving a stronger antibiotic they know will work (for now). The problem is, bacteria share the DNA for antibiotic resistance for whole categories of antibiotics when they mate, and resistance can spread across species through viruses that attack bacteria. In 1995, I wrote: All we need is for the vancomycin resistant enterococcus now plaguing hospital patients to share its tricks with the multiply resistant staphylococcus aureus, also a hospital favorite, and we will have a staph that is only resistant to unapproved experimental agents. Surprisingly, in 6/97, this has happened in the most contagion-conscious country on Earth, Japan. There, they even buy antibacterial clothing. A Staph with intermediate resistance to vancomycin has killed a little child there. It has since been seen in California and New Jersey. We should probably get focused on robust health and strong immune systems so we can avoid infections, and fight them off ourselves should they occur. Group A Strep (the disease causing kind) is in the mouths of 20% of people. Maybe a kiss gave me the bacteria but I only got the disease after freshman finals. Do you see the correlation with stress? Antibiotic development is an arduous process flavored strongly with luck. Its not like Star Treks Doctor McCoy whipping up something new in 10 minutes in the Enterprise sick bay. Believe me, we are quickly entering the post-antibiotic era. It would mean a pimple could kill you. It would mean a return to surgery and prayer for infections. Antibiotics are convenient, but each one is given to us for our prudent use, each has a limited duration of usefulness, and we need to destroy their usefulness slowly enough that we have discovered other effective agents to replace them. I look carefully for evidence of focal infection. In an immunocompetent person, this means a persistent fever over 101.5¡ and a painful pocket of pus, or a characteristic lesion that reliably means a particular bacteria is responsible. There is usually time to culture and treat bacteria specifically, which means antibiotics are offered that killed them on a culture dish in the lab. I have seen outpatient sputum cultures turn up bacteria that are resistant to every common antibiotic and most of the extended spectrum ones. I do not want a person to suffer, so drainage of the area in question is encouraged with medicine, and pain relievers can be offered. A blood check for evidence of an allergic basis for the symptoms can be done, because shots have been shown to be effective. Many are relieved to find that their throat or sputum culture had no disease causing bacteria, and they are indeed feeling better on the decongestant. Doctors used to joke, this will get better in 7 days on an antibiotic, or one week without one, and patients would figure it out [and probably still get the antibiotic]. This is the Nineties, though, and patients want more. I want to give more, too, and so here it is in writing. Bless us both, I have a sincere interest in treating you, but not over treating you (and dooming us), so trust my Board-Certified opinion regarding your need for antibiotics, and do not be frustrated that you may be leaving the office without them.

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Doctor, I want a pill to lose weight. My friends are getting it and have lost weight is usually next. It is natural to want a pill to do something for you. Alice in Wonderland had solutions to make her small and big. The child in each of us wants that magic. But the real weight loss pill is exercise, as vigorously as one can, 20 minutes twice a day, at least 6 days a week. Various doctors made a bundle promoting fenfluramine, phentermine, and dexfenfluramine, even over the Internet without seeing patients. Then the sky fell. The FDA banned them. I noticed on 12/31/97 that Dr. Paul Rivas had a garbage bag taped over the weight loss center part of his sign on his door. Quite appropriate. Patients spend $80/visit for diet doctor therapy and pay for the medicine out of pocket. Its my opinion that these offices operate like little crack houses, with patients often dictating how many pills of various colors they want. I feel that it is immoral for a doctor to sell addicting pills out of his office because it is a violation of the patients trust. He cannot make a profit and offer them without bias. Even some psychiatrists are doing it, which is especially nefarious. Many doctors are afraid of declining incomes and are selling their morals a lot of very dirty income, because it is stained with their patients blood. Look in any edition of Physicians Desk Reference and you will find that these drugs offer only a fraction of pound of weight loss per week over placebo [a dummy pill], that long term safety has not been established, that the drug should be discontinued rather than increased when the effectiveness diminishes, as it always does, and that weight returns on stopping the drug. The new one, Redux, is restricted in France to people over 130% of their ideal body weight [IBW] because of its deadly side-effects, and yet, after a year of therapy, less than 10% of patients get to 110% of their IBW. The answer is daily aerobic exercise and sensible eating forever - they are not punishments any more than a pill could be the solution. Doctors must first Do No Harm. I heard a diet doctor has pursued nurses and student nurses onto their wards, enticing them with the hard sell; he has hoping they will mention it to all their patients. These diet pills have been shown to cause stroke, fatal pulmonary hypertension [high lung blood pressure] and heart valve defects; they frequently cause anxiety and insomnia. A new major side effect is revealed every season. My own Medline search of the topic is available on request. There is one physician who did his own computer search and went on both agents for his alcoholism. Then he put his depressed wife on them and then their retarded daughter, lost hospital admitting privileges and so tried to put all his patients on them; those who refused were no longer seen, nor were those who could not tolerate the drugs, although these were not treatment failures in the physicians mind. He therefore felt that he had a 100% success rate. This is a gross failure of the scientific method in an drug-fogged mind. The FDA felt so too and has investigated. But once a drug is approved, it can be used for any indication a doctor sees fit. Harvard physicians fought the approval of Redux, but it was pushed through FDAs usually slow process by millions of dollars of funding. It later came out the main researcher involved had an undisclosed financial interest in one of the companies developing the drug. Of course, obesity is an important deadly problem. Lets just not kill people to treat their problem and pay for the doctors luxury car. Herbal fen/phen or ephedra is no better: as little as 40mg has killed people and yet you can find it in a pleasant little bottle a few feet from organic vegetables at the health food store with no warning label [like, poison, keep away from humans and animals, the FDA suggests limiting intake to 24mg a day in divided doses], or as herbal ecstasy that promises a high and may simply kill those in the really hip* crowd. [*= hep, buff, hot, rad, whatever; death is cool, but only literally].

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Vitamins: The news is full of vitamin stories. A hundred years ago physicians and scientists were zeroing in on the causes of diseases caused by dietary insufficiencies, like beri beri, scurvy, and rickets. Foods that would cure these diseases were found and vitamins were extracted from them. A great milestone in American health care was establishment of the Recommended Daily Allowances. The RDA compelled the addition of vitamins to milk and bread and educated people to eat a sufficient variety of foods and nutritional diseases became rare in this country. For centuries patent medicines have been sold that purport to contain healthful ingredients; this process goes on today in health food and vitamin stores. Early in medical school, I was very excited to learn of a vitamin program that promised all sorts of benefits, including hinting at being age-retardant because of its precise balance of micronutrients and anti-oxidants. Nobel laureates were on the companys scientific panel; sports stars were spokes people. Not receiving literature I requested from the company on the basis for their claims, I dove zealously into the medical literature. I found nothing to substantiate the claims. The micronutrients like selenium were present in adequate amounts in vegetables and deficiency had only ever been demonstrated in China. The anti-oxidants were made by our own cells and would not be able to diffuse across cell membranes. The bioflavinoids from orange peel had no nutritive significance, despite exhaustive computer searches. I was trained at Hopkins to Òlearn how to learnÓ and analyze claims and data for their logical basis. Any scientific hypothesis needs to be replicated by independent researchers; it needs to make biological sense; ideally a hypothesis would be demonstrated in a prospective way, that is, looking forward instead of backward at a process. A Nobel laureate, Linus Pauling has taken several grams of vitamin C for years and is now touting the benefits of vitamin E in the prevention of heart disease. The jury is out on what different vitamins can prevent what diseases and in what dose they should be taken. It should be noted that large doses of vitamin A are fatal and stopping large doses of vitamin C can cause scurvy. 200mg of C saturates the lens and can help ward off cataracts in conjunction with UV protection and smoke avoidance. I cannot argue against a inexpensive daily multivitamin, and there was a well done recent study that showed muscle ache was reduced in aerobic exercisers by 200 to 400IU of vitamin E, and I find this to be true for myself. This is a dose of vitamin E is being investigated for its ability to protect against heart disease. When give to smokers, beta carotene has been shown to cause more cancers. The vitamin industry is very poorly regulated and full of hucksterism. It is OK to take a multivitamin and an E supplement, but go generic; sometimes I have not been able to convince a patient out of a $100/month vitamin bill. They will not reverse the damage of smoking, a high fat, low fiber diet and a sedentary lifestyle. The life-prolonging effects of stopping smoking starting aerobic exercise and eating a high fiber low fat diet have been proven in thousands of studies, and this has not been done with vitamins, although there has been plenty of time to do so. If someone offers to sell you vitamins for a few dollars a day, ask them if they can hand you the publications that prove in a prospective, double-blind randomized placebo-controlled study that vitamins have any impact on illness or mortality. I have searches available on melatonin, coenzyme Q10, pycnogenol and others, so ask me before you invest.

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Herbs: I will here list the herbs that are deemed efficacious [they work] and safe by sound research and not hype. My favorite references are Medical Botany [1980] and The Honest Herbal [1993], the latter by Varro Tyler. It is best if you refer to this latter reference before buying any herbs to ensure the best genus and species of plant; lack of contaminants, and guarantee of identity by the store is a must. One eliminates these problems by growing ones own. I have not mentioned uses because you should read the monograph in the book and we should discuss any questions you have before you try anything. I have only listed those herbs with medicinal uses; typically they may have an effect like cathartic, but, so sorry, they are not effective as aphrodisiacs or to rejuvenate. Neither have I listed diaphoretics, flavors, beverages or foods if these are the sole effective uses. Of course, you use all of these things at your own risk.

efficacious and safe :

efficacious and safe, except that long term use of tannin-rich herbs may be carcinogenic:

maybe efficacious and not safe

not efficacious and safe

alfalfa,
boneset,
burdock,
catnip,
chickweed,
damiana,
devils claw,
fo-ti,
gotu kola,
horsetail,
kelp,
lettuce opium,
papaya,
red clover,
any bee product except pollen, propalis,
sarsaparilla,
spirulina,
yucca

not efficacious and not safe

There is a ton more data in the first book, Medical Botany, especially regarding herbal habits internationally, including the organic chemistry and physiology, for those with that bent. The Internet has been unhelpful to me so far, in that it mostly purveys products and hence the data is unreliable. Other interesting facts. Garlic had been mentioned for cholesterol. Chewing a small amount has antibacterial action in the mouth and can ward off sore throat germs. One aspirin a day reduces the chance of heart attack, stroke and colon cancer; aspirin was developed from willow bark which has been used as a tea for centuries. Smelling Oil of forget-me-not, and maybe any scent, increases the rate at which a person can memorize new data and correctly recall it. Ginseng [panax quinquifolium] decreases telegraph transmission errors and permits rats to swim longer in ice water - - this has not been tried in medical students. But I read a whole book on ginseng after Pam bought me two roots for the garden. A squirrel quickly got one and ripped the other one out of the ground. The book revealed that ginseng farming requires the use of all sorts of off label and hence illegal pesticides, herbicides, rodenticides and fungicides because ginseng wants to grow scattered in the woods by birds, not 2Ó apart under artificial shade. Any amount of pesticide is inappropriate, and could destroy any positive results that one obtains. Of 30 ginseng products in the Health Concern I noted only one claiming to be organically grown. Ephedra, or Ma huang, or Herbal Ecstasy, has killed 20 people in this country as a newly popularized supplement, so while I am knowledgeable about medical botany, I am cautious. After all, you could almost certainly find a mushroom within block of where you are sitting that could kill you. Unfortunately, people have tried this, and it has killed them.

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Appropriate health screening:

cholesterol

flexible sigmoidoscopy

mammography

calcium

over the counter medicines

oral rehydration therapy

In younger people, were still not sure when to check for high cholesterol, except that we ought to, what it means, except high is bad, and which treatments at what times, benefit patients, except in patients with angina, heart attack or stroke. If your fasting cholesterol remains high, e.g. over 200 total or LDL over 120, and I want to suggest the following nonprescription means of lowering it. Daily aerobic exercise, walking is fine, work up to 30 to 45 minutes daily, the best being at least 20 minutes twice daily. Add more fruits, vegetables and whole grains and bran in your diet. Garlic, one or two cloves daily, even for a few weeks reduces cholesterol significantly for more than 6 months. Crystalline niacin 250mg one twice daily for a week, two twice daily for a week, three twice daily for a week, four twice daily thereafter, each dose with one aspirin to help reduce the chance of flushing. Patients have found this form of niacin, which more effective than the slow release, at the Health Concern at 28 Susquehanna Avenue in Towson 828-4015.

If your cholesterol remains high on these measures, it may become necessary to begin a cholesterol lowering medicine. Better and cheaper are the power of exercise to prevent and reverse heart disease, and the ability of three or more fish meals a week to cut the risk of sudden death by 80%.

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flexible sigmoidoscopy
Polyps are growths in the colon, that bleed only intermittently. These can be removed easily without surgery. They become cancers over 5 to 15 years if not removed. A full 90% of colon cancers can be prevented simply by removing polyps. The National Cancer Institute recommends a procedure called flexible sigmoidoscopy to look at the last 2 feet of colon and rectum to make sure that there are no polyps or cancers that could be removed before they cause bowel obstruction or spread to other areas of the body. The procedure is done after the patient does two enemas at home. the procedure takes about 15 minutes, can include some gassy discomfort and is very safe even if biopsies are done. This procedure is indicated at age 50, 51 and then every 3 years unless a first degree relative has colon cancer. A mans prostate check is done at the time of the procedure. If polyps were found the entire colon would be examined at a second procedure called colonoscopy. I do flexible sigmoidoscopy at GBMC.

I hope you will let me do this procedure to nip this in the bud; an ounce of prevention is worth a pound of cure. I have seen every possible complication in patients who were not given appropriate preventive screening and it is always a relief to find no polyps or send someone on to a simple polypectomy; then I feel I have really helped.

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Mammography, breast self examination Every woman must do their own breast self examination every month either on the first day of her period or on the first day of a new months estrogen replacement. We are all responsible for our action, or inaction about this. do not be afraid, most lumps are benign and finding a mass early will save your life. do not be passive and assume the Gynecologist or myself will find it ourselves when you next happen in; report any of the following: 1. anything new; 2. anything that holds down to the chest wall; 3. any dimpling of the skin or new asymmetry; 4. any change in color of the skin; 5. any discharge from the nipple. Memorize these points and review them as you feel each breast with the pads of your fingers and observe your breasts in the mirror. Of course, your breasts have some density already, but breast cancer is often very hard - like the bridge of your nose compared to your cheek, or like feeling a marble held in your cheek. Remember to feel up toward your arm pit, because breast tissue extends that way like the tail on a comma.

Mammograms have been extensively advertised over the last 15 years; we had just then realized how important they were and wanted to get the population up to date on them. However, research during that time has now shown that mammography, under age fifty without an observed lump, does not reduce disease or early death from breast cancer. Both mammography and non-mammography groups did their BSE faithfully. So, the National Cancer Institute changed its recommendation in November 1994 to mammography every one to two years beginning at age 50. Baseline mammography is not indicated, because youthful breasts are dense and suspicious lumps have well defined radiographic characteristics that are distinct from this appearance. Baseline has always been an inadequate excuse made up by doctors who sometimes would refer you to a facility in which they had a financial interest. There are laws against this now, but they are easily circumvented. Now, the American Cancer Society and NCI decided that they would better let women decide for themselves about mammography between age 35 and 50.

It is good to start screening mammography earlier in women whose mother or sister had premenopausal breast cancer. If you do not meet these criteria, do your BSE faithfully and do not worry. Please ask me to calculate your absolute risk of developing breast cancer over the next five years, as an algorithm is available. Tamoxifen is available for prevention of breast cancer, although 1,825,000 pills in 1000 women over 5 years are required to reduce the number of cases from 17 to 10. Raloxifene is also under consideration. Both are handy at treating osteoporosis too. Maybe both together is Òthe cure.Ó We will see.

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Calcium: This section is close to the BSE because it is especially important for women. Our great grandparents all got about 2000mg of calcium in their diet. We get 300mg on average. There is 300mg in a cup of broccoli, yogurt or milk. All women over age 8 years should get calcium carbonate 1500mg daily to improve their bone density, by up to 10%. Weight bearing exercise like walking helps much more, and tennis players have 50% more bone in their playing arm because piezoelectric stresses on bones encourage them to become denser in all the right places. Light weight upper body work outs help prevent wrist fractures, the most common after hip and back fractures. During menopause, women should strongly consider estrogen replacement therapy to maintain this density, because estrogen also protects against heart attack and stroke, and Alzheimers, and any increased risk of breast cancer by it is tiny or nonexistent. Men over 65 need 1000mg/day, which is what I take.

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Common over the counter interventions: You do not have to take acetaminophen [Tylenol] 1000mg four times a day for fever, as your white blood cells bacteria-killing power is increased by 10% per degree Fahrenheit, but usually the headache with fever pains me. Over the age of five, there is little risk of a seizure with fever. For fever persistent despite acetaminophen, try a two Advil chaser [ibuprofen 200mg each]. For post nasal drip that usually gives sore throat, pseudoephedrine as directed helps greatly, and for those on blood pressure medicine, usually only raises blood pressure slightly, and this is OK on the short term. Cough responds well to guaifenesin and dextromethorophan. Immodium is good for diarrhea as long as there is no fever, or blood in the stool. For a sprain, five things to do are to take ibuprofen 800mg thrice daily, and RICE: Rest - lay off the activity during which you were injured, Ice, Compression with an ACE wrap and Elevation.

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ORAL REHYDRATION THERAPY As soon as you realize you are sick or have a fever, start drinking plenty of fluids. Because if you do not, you will get dry enough that you cannot keep fluids down, and you will need an IV poked in your arm to get caught up - - no fun!

We can expect to be dizzy and nauseated if we lie around for hours and then try to jump up and drink cold water at the sink - - were too tall! People call me with this story all the time. Or, they try not to drink because they are afraid of throwing up. Oops, wrong! This makes uncontrollable vomiting more likely. Illness makes our arteries and veins relax so much that our blood pressure is low standing up; to keep blood flowing to the brain, heart, our gut blood flow drops to nothing. We need gut blood flow to absorb fluid by mouth, or we throw up. So, take a 2 quart pitcher to your bedside, lie down and drink from a big cup with a bent straw. The World Heath Organization suggests a pinch of salt, a teaspoon of sugar per cup of water; you can drink juice or broth diluted 50/50 with water and alternate between them, or just start with water. We can all swallow little sips flat on our back or certainly on a single pillow (we can actually swallow while standing on our head - - do not try this at home now). Hydraulically, it makes sense that we feel a lot better being 10 inches tall rather than our usual 5 or 6 feet. My patients have had a 98% success rate with this approach.

When I last got sick, I drank 6 quarts in 12 hours and I crawled to the bathroom. We need to drink as much as possible until we make urine (make water, pee, urinate, micturate, etc.). This is a critical step because it means we have absorbed enough water that our kidneys are seeing more of it and decided to let it go to the bladder. Then keep drinking enough to urinate at least every two hours. This is likely to be a lot, since we lose a quart a day breathing out moist air normally; if we sweat and have a fever we lose quarts and quarts. At maximum exertion, a healthy athlete can go through 10 quarts an hour!

Over-the counter Emetrol can quell nausea if you are still having problems getting started with ORT. If you are still vomiting, I can call in compazine to your pharmacy (please have the telephone number handy). And do not hesitate to call me with concerns and questions, this sheet does not imply you are now on your own - - I am there for you any time. On a rare basis nausea and vomiting are more serious processes; I need to know right away about associated chest pressure, shortness of breath, blood in the stool, or focal abdominal tenderness.

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Resuscitation
It is difficult to begin a discussion like this. When patients become very ill, it is best that the people caring for them understand what a patient would want done to prolong their life, and under what circumstances. It was simple 70 years ago; there was little medicine could do. Now, the act of dying can be drawn out by technology in unmerciful, painful, humiliating and dehumanizing ways. This is because we can replace various essential functions of our being. But these are best applied when the hope of functional survival is good and not unlikely. Somehow the soul can escape unnoticed from amongst all the tube and wires, and yet the body is forced to live on by machines. Doctors are often afraid of their own Death, and are loath to give their patients to him, because he is the enemy. He takes what they are trying to preserve, which is life at all costs. No one need be afraid. We need to preserve functioning, thinking life, and learn to let go when it is time. What such doctors actually attack is the patients failing systems; what they invade in this battle is the patients body. Most have never had an IV in their arm. Few if any have been admitted to the hospital. None have had a tube holding their vocal cords apart forcing air into their windpipe, or tubes passing food and collecting urine and feces in their bodies. None have floated in the black cloud during a fatal heart rhythm, only to be kicked like a mule with electricity and be brought back to a consciousness of crushing chest pressure, more tubes, and more wires.

I am here to care for you. That includes merciful comfort through situations that are not remediable, that cannot be cured. It includes doing what you want, although doctors are not obligated to offer therapies that are futile, nor should they be offered. You have a right to refuse any therapy at any time. My duty is to you alone; sometimes I disappoint a family when I do exactly what you ask and they wanted more, or less. Interesting that only 40% of the elderly are in favor of assisted suicide, and 70% of their heirs are. I am not here to kill you. You have the right to change your mind about how much or little you want done at any time. Your life is your own, and I am here to defend your right to choose treatment or non-treatment as you see fit. If you refuse resuscitation and you need it in the future, you will die, but I respect your choice either way. I will not abandon you or treat you differently because of your decisions. I will not be angry. I am sad to see someone leave that I have come to know, but I am honored to know that I helped their natural passage be a comfortable, peaceful and dignified one.

It is important to say that if you are found not breathing, and have not refused resuscitation, it will be done to you. This means someone will give you breaths, and, if your heart is not beating, chest compressions [CPR]. When the means arrive, your still or shivering heart will be shocked back into organized activity, if possible, by direct current electricity [defibrillation]. A tube is run into your windpipe and secured using a balloon there and a strap around your head [intubation]. Large IVs will be placed in your veins and fluids and medicines injected to stabilize the heart and raise the blood pressure. You will be transported to an intensive care unit. I promise you all this will be done without regard to your diagnoses, even if there is cancer throughout your body; I am quite angered at the recent insistence that if the folks from 911 [MIEMS] do not see their bracelet on your arm saying you do not want resuscitation, you will be resuscitated, even if nurses then discover on your chart your stated desire to pass peacefully [this is battery and there ought to be a class action suit against such insane protocols]. It is therefore of the utmost importance that I understand your wishes, and that you make them known to your family and anyone that might call 911 down upon you.

The problem is, unless you have your heart electrically monitored all the time and have a defibrillator on or near your body, like in an intensive care unit, you are unlikely to survive resuscitation to resume life outside the hospital as a walking, talking person who remembers where they are, recognizes family members and enjoys life. Some teaching hospitals [that teach doctors in training] have found the prospect of resuscitation so grim for a full arrest [a patient with no pulse] in the hospital, that they have privately suggested not offering it to patients. However, there is a lot of money to be made in offering these unmerciful services, which is something I had no concept of until I was finished with my training. I worked 6 months per year for 3 years in intensive care units, and I learned how to identify and treat fatal processes so well that I brought patients back that my colleagues could not. I had no time in such crises to stop and ask families, Òwas this what the patient would have wanted?Ó I had to train my own juniors, and I was evaluated by them on the opportunities and teaching that I offered. I could be severely reprimanded by my seniors, or even kicked out, destroying my future, for not doing exactly as I was told. I have escaped that grim hierarchy, and emerged from its sleep deprivation. Now I can tell the truth. A resident doctors contract with a hospital specifically forbids him from talking to reporters about how they feel about the institution.

If you do not want to be on a breathing machine, tell me so. Again, you can change your mind anytime. I will write on the chart that you are not to be resuscitated usually specifying no CPR, no intubation, especially in the hospital. In addition, you may refuse surgery procedures, cardiac monitoring, cardiac medicines, blood pressure raising medicines [pressors] ( these three would go together), Iv antibiotics or fluids, transport to the hospital, food, fluid or oral antibiotics where you live. It makes sense for you to accept oxygen or pain medicine as comfort measures, but I would withhold them if you asked.

While you are mentally competent, it important to establish a durable power of health care attorney, by stating which relative or friend this is in writing on my chart, and/or the nursing home or hospitals charts. This power should be passable through a series of people in the event that the first person you designate is not able to make health care decisions for you. If you do not designate anyone, I will turn to the next competent next-of-kin to help make decisions for you. I do not want you to spend an arm and a leg to get all this in place with legal advice. Your wishes can be made verbally to me; I will write them in the chart and respect them. It is best if you write down your thoughts and discuss them with your family so they understand what should be done if a crisis unfolds. In addition to the advanced directives sheet that follows, it is important for everyone, regardless of age to make a will. It is important to consider the possibility of organ donation. I am an organ donor.

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Living Will/Advance Directive:
I, ________________am an adult, and I am of sound mind, and I write this documents a directive regarding my medical care. I intend this document to be my Living Will and Durable Power of Attorney for Health Care. [Initial the choices you want]
Part I: Appointment of a Proxy. I appoint the following person [not my doctor] to make health care decisions for me if cannot communicate these decisions: ____________________________.
Part II: Directions for Medical Treatment
I want the person appointed, as well my doctors, to be guided by the choices I have indicated, following:
A. These are my wishes for medical care if I cannot make my own decisions and I have a __________terminal condition and or a ___________ persistent vegetative state:
_______I do not want a tracheostomy or gastrostomy. Discuss these interventions with your doctor to understand them.
_______I do not want chest compressions or intubation and artificial ventilation.
_______I do not want invasive monitoring or blood pressure raising medicines.
_______I do not want dialysis.
_______I do not want artificial nutrition.
_______I do not want hydration.
_______I do not want intravenous antibiotics.
_______I do not want oral antibiotics.
_______I do not want transfer to a hospital.
Other wishes ________________________________
Organ Donation
_______I do not want to donate organs.
_______I want to donate ______ all organs. _______ these organs: ______________________________________
Your Signature __________________ name/address ____________________________ date _________________ . I believe the person who has signed this advance directive is of sound mind and that he or she signed or acknowledged this Advanced Directive in my presence and that he or she appears not to be acting under pressure, duress, fraud, or undue influence. I am not related to the person making this directive by blood, marriage or adoption, nor to the best of knowledge
Witness Signature __________________ name/address ____________________________ date _____________.
Witness Signature __________________ name/address ____________________________ date _____________.

Epilogue I have tried to put this information in a format and sequence that makes sense. Of course, there is much that I have not included; I am working on a web site for fall. An English teacher patient said, the data was kind of stream of consciousness. I prefer to think it represents an expanding volume of consciousness, but where to start, and how to progress, is an ongoing issue. I welcome your input.

e/address ____________________________ date _____________.