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Is your skin the largest organ in your body?
That is a trick question that every medical student answers wrong at least once. The answer is “yes.” (Med students think of the heart and liver etc, and don’t realize the skin is an organ.) Given your skin is your interface with the world, it takes a fair amount of abuse. Yet despite this, it is a miracle of design and mostly stays intact.
The skin has much in common with a leather armchair at home. It is pretty hard to cut, rip or tear. It lasts almost forever, but looks pretty worn, even when it’s new.
The skin is covered with layers of dead epidermal cells. This is the body’s version of GORE-TEX® breathable shell. It is waterproof but allows sweat to escape. The waterproof part is absolutely essential to life. Your blood needs to be kept in a narrow range of sodium concentration (and other elements).
If your skin was freely permeable to water vapor it would dry up like a raisin. Skin is important for maintaining body temperature by controlling your sweat glands. Your body is fussy about staying at 98.6.
Going deeper into the skin we find the dermis. This is the strength layer of the skin. It has collagen and elastin elements. The collagen is what ligaments are made of and is very strong stuff. Its job is to keep the insides where they belong. Most of us are more concerned about the elastin. The elastin puts the tone in our skin, much like the waistband on your underwear. When the elastic/elastin breaks down, your shorts sag. Ah, but if only Fruit of the Loom made faces.
Sun and time inevitably break down elastin, keeping several industries busy.
Think of yourself as a rainforest. The skin has a unique ecology with tens of thousands of different bacteria, fungi and viruses. We mostly live in peace with this community, a quiet day in the rainforest. We have various relationships with these organisms from commensal to parasitic. Mostly they take up space on our skin and prevent something worse from growing. Kind of similar to “a healthy lawn grows few weeds” sort of thing.
Now the surface of skin looks more like a Thomas’® English Muffin than porcelain when magnified. There is oil on the skin surface secreted by sebaceous glands. Most of the bacteria live in this oil layer. That’s why we wipe you off with an alcohol pad before giving an injection. The alcohol acts like a solvent to remove the oil.
When you cut or chafe the skin, your own bacteria contaminates the wound and starts to grow. If you wait 12 to 24 hours there will be enough bacteria growing in the wound to cause an infection if the wound is closed (sutured). That is why it is important to close wounds promptly. Most wounds do best if closed within 12 hours. Some doctors don’t like to suture after even eight hours.
So if you think you might need sutures, get it checked out; right away. Until we get re-upholstery shops for bodies, we’d do well to keep the skin we have in good shape.
There are several things working against our desire to remain youthful — oxygen and age. Good luck avoiding either one of these. Oxygen is absolutely essential for life, but oxidizes pigments (free radicals and all that). Sun and oxygen combine to oxidize your house paint, making the color fade and develop cracks, not unlike sun-damaged skin.
Oxygen and sun (UV radiation) also cause breakdown of the elastin fibrils as we said before. Staying out of the sun, or using sunblock, is probably the single most important thing you can do for your skin.
Skin also likes moisture. Your skin will never feel softer than after a week in the tropics (rainforest). You might be bug bitten, grow mold, and have interesting hair, but your skin will feel great. Having said that, moisture from the inside is actually much more important than moisture from the outside. Remember the dead epithelial cells layers don’t let much into the skin from the outside.
What about the cosmetic industry? All the creams in the world will only work like a good leather conditioner. They might soften up the feel and prevent some cracking but they won’t create new skin. I hate to think of how many billions is spent on magic creams; my wife must have a dozen of them.
So if magic creams don’t do much, how about more radical approaches? You can sand down some of the outer dead skin layers-dermabrasion (or facial road rash). That will soften it up, and because it is so traumatic, the skin will be swollen for a while. The swelling stretches out the wrinkles. Kind of the healthy glow of road rash.
As a last resort, simply remove loose extra skin, thus tightening up the rest. Your neighborhood plastic surgeon can help you with that. Think of your underwear again, that stretched out old elastic waistband will stay on your backside if you take out a couple of inches, with a safety pin for instance.
You will still have crackly old elastic, but it will fit better — for a while.
So be mindful of the care and feeding of your skin. It’s the only part of you the world gets to see.
Take care of yourself (really).
You may have a serious case of righteous indignation with the superficiality of life, or perhaps just the winter blues. While we don’t specialize in existential funks, we know something about depression and its cousin, colorfully named Seasonal Affective Disorder (SAD).
Our brains are immersed in a neurochemical and hormonal stew that is dauntingly complex, but a lot of work in the last decade has given us understanding of at least the broad strokes. It’s pretty complicated up in the head.
It is completely normal to slow down some in the fall; your body is conserving energy to get you through the cold winter.
For up to 10% of people, this is much more than simply banking the fires; it is a life changing and unwelcome annual ordeal. An affective disorder is a fancy way of saying a mood problem. The namesake symptom of SAD is depression.
Depression is usually associated with varying degrees of fatigue, increased need for food and sleep, weight gain and difficulty concentrating.
This occurring during the holidays is particularly irksome – when the need for energy is greater than normal. The increased appetite when the house is full of Christmas cookies is torture to anyone trying to maintain an ideal body weight.
An additional 10% of people have a milder form of the condition that may only have fatigue as a symptom.
The scientists tell us that the decrease in daylight triggers a decrease in brain serotonin and increase in daytime melatonin levels. You probably remember serotonin; that is the brain chemical that Prozac increases. Serotonin is good.
You would be right in deciding that medications like Prozac would be helpful in Seasonal Affective Disorder.
For those inclined toward more natural cures, we just need to trick your body into thinking it’s summer.
Your body mostly wants a sunbeam, like a cat. That is something we know how to do. Light therapy is essentially a portable sunbeam. The UV light is filtered out so you won’t get skin cancer, or unfortunately, a suntan. Light therapy with the intensity of 10,000 Lux seems to work the best, with 30 minutes every morning commonly recommended. Sitting in your sunbeam after work can also help, but occasionally causes insomnia. This treatment actually can work in as little as a week. That is three times faster than is usually seen with medical pill treatment.
Melatonin is also commonly used to treat Seasonal Affective Disorder. Melatonin is a hormone that is produced by your body in dim light. Taking supplemental melatonin in the afternoon can reset the hormonal clock.
Light therapy isn’t the only unusual treatment for SAD. Use of a negative ion generator in the bedroom at night shows a 50% response in patients with SAD.
Medications of the SSRI class work well but take a few weeks to become effective. Prozac is the best known SSRI, but any of them are effective.
The seasonal nature of Seasonal Affective Disorder favors the non-drug approach to the disorder. In people with SAD it usually returns each winter. Light therapy can be started in the fall before symptoms occur and can be useful in preventing the onset of SAD. Many find this more palatable than starting and stopping medications every year.
Seasonal affective disorder is often the cause of winter blues. A variety of treatments are usually well tolerated and effective. In the meantime, have a Christmas Cookie, can’t hurt.
Periodically, we re-post some of your favorite blog posts. We’re offering two that are timely today: precautions to take for winter weather and flu shot myths.
Baby, It’s Cold Outside: Winter Weather Precautions to Take
Winter is here! Anyone out and about in the cold, wet weather is at risk for some temperature-related injury if they do not follow some basic common sense precautions. Understanding what things make you at risk can help prevent mild and severe cold-related problems.
Top Ten Flu Shot Myths: Don’t Fall for Them
It seems most people won’t get a flu shot this year – many turning to what can only be called the Top Ten Flu Myths. Here goes:
Thanksgiving is my favorite holiday. The perfect Thanksgiving holiday consists of making the house smell good, cooking a wonderful feast, being surrounded by family and friends and counting your blessings. All quite doable, and I’m even the cook in the family.
And what a feast it is.
The average Thanksgiving dinner meal is 3,000 calories. And that doesn’t count my gingered cranberry sauce with pecans and pineapple (good enough to eat with a spoon), but I digress.
Scientists who have run out of useful research have turned their staggering intellects to our simple Thanksgiving fare and have discovered some interesting facts.
When it comes to these dinners, the more guests you have, the more consumption per person.
The average Thanksgiving dinner participant will eat an extra 35 calories for each guest seated at the table; a case of “the more, the merrier.” More people means more conversation and more time at the table, with predictable results. Distraction also can run up the calorie count. Watch football during dinner and you will add 140 calories to your meal.
Your digestive system has been around far longer than Stove Top Stuffing and still worries about lean times. Being able to gorge on a high fat meal just might get you through the next ice age. So your stomach expands in response to the sight and smell of food. Low fiber, high calorie foods classically associated with Thanksgiving dinner also are rapidly absorbed, giving you room for more.
Those hoping to offset the caloric onslaught by fasting for a day of two, just make it worse and eat more at the Thanksgiving table. Thanksgiving gluttony has even developed its own vocabulary: “uncomfortfull” or “Turkey-Hangover” are two examples.
But there is hope and a few tricks to get you through the meal with less than mortal damage to your diet.
First and foremost, don’t starve! Going to the Thanksgiving table hungry is the recipe for trouble. Eating a bowl of cereal or a cup of soup several hours before dinner will pay dividends.
Eat slowly. Give your body a chance to tell you it’s full. Feelings of satiety are basic hormonal signals that travel much slower that nerve conduction. Your body is talking to you; you just need to pause and listen.
Under normal circumstances you could spend a bit more time with the vegetables, and be ahead. But Thanksgiving recipes have a way of even making vegetables calorie-dense.
Consider an appetizer. With a bit of planning, a well-chosen appetizer will slow down the kamikaze attack on the mashed potatoes and gravy.
Take your time and enjoy the day. The day is about counting blessings more than just food. The cook won’t complain if you don’t have “thirds.”
Editor’s Note: Exactly two months ago, U.S. HealthWorks doctor Anne Coatney was thrust into a tragic situation at the most unexpected time. Her story and how she handled it follows.
This sun-drenched afternoon in Reno, Nevada, was supposed to be the start of another memorable weekend for Anne Coatney. A big fan of aeronautics, she was back in a familiar place, her eyes transfixed on the sky as she sat in Box 68 at the annual Reno Air Races.
But for Coatney, a doctor for U.S. HealthWorks Medical Group in Seattle, the day turned tragic as a plane crashed into the viewing stands.
That Friday, Sept. 16, as Dr. Coatney attentively gazed up at the sky during the featured Unlimited Race, fear engulfed the tens of thousands of spectators as a vintage World War II-era fighter plane, traveling in excess of 450 mph, careened out of control.
“Practically everyone hit the deck around me, but I just stood up and watched it,” recalls Dr. Coatney. “I thought, ‘Oh my gosh, I may die!’ Everyone was fearful for their life.”
There was little advance warning when the modified vintage airplane slammed into the tarmac at Reno-Stead Airport, resulting in the worse accident – 11 deaths, 74 injured – in the history of American air race events. Before this year’s disaster, 18 pilots had lost their lives at the Reno Air Races since 1972, but never a spectator.
The plane piloted by Jimmy Leeward crashed near the grandstands around 50 yards away.
A doctor with 19 years of emergency medical treatment experience, Dr. Coatney took a quick look around her immediate area, then sprinted straight for the crash scene.
As she rushed to the accident location, in her path were debris from the plane, and several dead bodies, including a person in a wheel chair, but she remained focused on getting to those she could still help.
“I was running toward the crash. Your adrenaline takes over and you just react on instinct. I didn’t know I could run that fast,” Dr. Coatney said. “I immediately was looking for someone in charge and, luckily, I found him quickly. I told him I was an emergency room doctor and he told me to go to the red zone, where the most critically injured people were being taken.”
The first person Dr. Coatney encountered was a 54-year-old man who was in mild shock. His right arm was severed at the elbow and he had an open skull fracture. Because she had no medical equipment, soothing words and makeshift treatment were all Dr. Coatney could immediately provide.
“All I had were my hands,” she said.
She kept those hands busy, trying to stop the flow of blood while keeping the man calm and taking some vitals with the aid of her watch. For bandages, Coatney used cloth given to her by helpful spectators who were cutting up nearby curtains from the box seats. Eventually she managed to stop the man’s bleeding in several places.
After helping load the man into a helicopter, she was off to the next injured person, a woman who had two fractured legs, open wounds, internal bleeding, and was in Level 2 shock. Dr. Coatney later treated a 29-year-old woman who had problems breathing due to shrapnel sticking out of her chest. Her leg was fractured and she had a collapsed lung.
Exhausted and back at her hotel that evening, Coatney called the hospital and checked on all five patients she had treated.
Dr. Coatney said her three years of residency at an emergency department in downtown Detroit, where caring for 20 gun-shot wound patients a night was not unusual, helped prepare her for Reno.
“I have learned how to remain objective and just do what I was trained to do,” Dr. Coatney said. “I thank God I had such good emergency training from my ER director in Detroit. It helped me be ready for a disaster like this one.”
Dr. Coatney has been coming to the Reno show for 19 straight years. It was quite an ordeal, but Coatney insists that she will be back in Reno next year and sitting in Box 68 once again.
“When you look back on what happened, you just think that you were lucky to live through it,” Dr. Coatney said. “It makes you look at things differently and you think that every day is a gift. It was a life-changing moment. But I’m absolutely coming back. I’ve gotten to know so many people that come to Reno every year and I’m part of the aviation community.”
This is a question supervisors, bosses, and HR specialists ask themselves constantly, albeit quietly.
Everyone wants zero injuries and companies have been known to insist on watchful waiting before committing to medical care and a reportable injury. This is a risky game but I offer some guidelines that should help you avoid some of the deepest pitfalls.
Does this “injury” need medical care?
I will start with the disclaimer that the safest thing to do is have any injury evaluated. The injured employee will do better and you and your company will stay out of trouble. But, if I were a supervisor, I would want some help in trying to sort the serious from the nonsense.
In looking at a possible injury, the first thing an employer naturally considers is who the employee is. They are thinking of his HR file: attitude, reliability, productivity, attendance. Essentially, are they a great employee, or a marginal one? That approach may guide you in determining whether the employee will be here next year, or will get a promotion, but is the wrong place to start for work-related injuries as it has nothing to do with the outcome from a specific event.
So put down the HR file and start somewhere else.
A good place to start is with the “mechanism of injury.” That is a term for “what happened” – the employee got hit with a hammer, fell down, or lifted something heavy. Would you expect a serious injury from this particular circumstance? How much force is involved? For example: If someone falls off the loading dock onto concrete, and doesn’t land gracefully on his or her feet, a fracture is more than possible, even expected. The opposite circumstance is someone hitting his elbow against a doorframe while walking through an opening. That would not be expected to produce a major elbow injury.
So consider the force put upon the body at the time of injury. Rule 1: Big force causes big injuries. That tells you to be very concerned about even an apparently minor injury if there was major force involved. An employee falls off the roof — have them checked out, even if he attempts to brush it off.
Injuries come from outside forces acting on the outside of the body. Since the body is conveniently covered with flesh and blood, there is often physical evidence of this injury. Especially in an extremity, there will often be swelling, a black-and-blue skin coloring, tenderness and sometimes “it just doesn’t look right” – because there is a minor deformity. If it doesn’t look right, beware.
All of these suggest more injury rather than less. So the second rule is if it looks injured, get it checked out sooner. The third rule is to minimize downside risk. In medicine downside risk is a tragically bad outcome, disability, death, medical complications – of course, all very bad stuff.
Doctors are trained to instantly think the worst, and go about proving to ourselves it isn’t that bad. That approach avoids missing something important that will cause great grief if missed.
In essence, you ask yourself: “What is the chance of this becoming a big problem if it doesn’t get treatment quickly?” That is, admittedly, difficult to do without a lot of medical background, but we can suggest a few scenarios.
A head injury with even brief loss of consciousness or appearing dazed is concerning. This is a brain injury. Brain injuries are always serious, because they can turn out very badly very quickly. This employee needs to be evaluated even if he or she claims to be fine. The downside risk is too great not to aggressively look for trouble.
Broken bones can have really lousy outcomes if not taken care of. Quite often the injured employee can tell you they have a broken bone. They hear or feel the bone break. Believe them and get them checked out promptly. Foreign bodies in eyes are a very common industrial injury. The employee will tell you they have something in their eye. They are almost always right. If a foreign body is not removed it will become harder and harder to remove and put your eye and vision at risk. It’s always worth trying to wash it out at work, and if that solves the problem, no worries, but don’t waste more than 10 minutes trying to wash it out. If you can’t get it out right away, it needs to be removed by a doctor.
All employers attempt to separate the truly injured from the minor stuff.
A little common sense when combined with some thought about mechanism of injury, signs of injury, and downside risk will go a long way toward helping you make safe decisions. Of course, the safest course of action is to have a medical provider evaluate the injury right away, which is our recommendation.
We are a phone call away if you need specific and immediate advice.
After the almost continuous progress of medical marijuana toward legalization by states, the federal government is threatening to use the trump card of federal law to override state laws.
California medical marijuana dispensaries have been told to cease operations within weeks or face federal prosecution. This has always been a possibility and, while many are surprised and yell “unfair,” many more are surprised it has taken so long. Marijuana, for the record, remains an illegal federal schedule 1 drug.
Medical marijuana occupies a curious and singular position as a “quasi pharmaceutical.” Like prescription medications, it has uses in the treatment of certain diseases. Like prescription medications, it has the potential for abuse.
The federal government sees the potential harm from abuse overriding any benefit of medical marijuana. This is not to say there is no benefit, but the therapeutic ratio tilts toward more harm than good.
The unique position of medical marijuana is further demonstrated by the individual state laws that regulate the prescription and dispensing of marijuana. For the rest of the pharmacopoeia, the DEA regulates all aspects of the medication. The drug manufacturer must make the drug of a certain purity level, it must be free of other harmful chemicals, and must be of a certain strength that is measurable and virtually identical batch to batch. It also must be proven effective for the condition for which it is approved. Those prescribing are highly regulated (medical doctors) as are the pharmacists and pharmacies that dispense medications.
Medical marijuana is also unique in its “sig” (medical language for prescribing instructions). If you look at medication bottles you have had, they give specific directions (i.e., take 1 tablet 3 times per day with food). The instructions for medical marijuana are to essentially use as much as you need, as often as you need, for as long as you need. I can think of no other medication either over the counter or prescription that has that latitude of use.
That being said, marijuana does have some benefit as an appetite stimulant for people with diseases like cancer or HIV who can benefit from that stimulant. It also can benefit patients experiencing nausea from such things as chemotherapy. However, experience has shown us that 90% of patrons of medical marijuana dispensaries don’t have cancer, HIV or what the mainstream medical community sees as serious diseases that cannot be successfully treated with conventional medical treatments.
What it comes down to is the present patchwork solution to marijuana legislation is simply unworkable, requiring a resolution at the federal level. It needs to be either treated like a drug, a medication or classified like alcohol.
Treating marijuana like a medication would involve marijuana being produced by licensed drug companies, in a standardized fashion, with frequent inspection and quality assurance programs. Marijuana, the medication, needs to have standardized levels of THC (Tetrahydrocannabinol), ensuring patients get the same effective dose each time they use it. This would be sold and distributed by pharmacies, with licensed and trained pharmacists. This is unlikely for a number of reasons, not the least of which is that smoking anything causes lung cancer and large pharmaceutical companies or large pharmacies don’t want that liability or damage to their reputation.
Treating marijuana like alcohol at least on the surface appears workable.
This would involve some standardization of product, federal or state inspection and presumably paying state and federal taxes.
Restrictions could be placed on the sale or use of marijuana by underage people.
What we have now is not a solution, but an anti-solution. We should start with a clean slate and appoint a blue-ribbon panel of recognized experts to analyze the risk and benefits of marijuana use. These experts could examine or commission serious scientific research and make reasoned decisions based on fact, not opinion.
We spend a lot of time each fall talking about influenza and flu vaccine. A great deal of hard work by very smart people goes into making this magic fluid each year.
The first thing you need to make flu vaccine is a flu virus. Those come in many different flavors, some old standbys trying to make a comeback, occasionally some new virus. Because the earth is tilted, our summer is the Southern Hemisphere’s winter. They are having this year’s flu season 6 months before we do. The best place to look for new influenza viruses are poor rural areas in Southeast Asia. In these areas, humans and animals frequently live close together. I’m sure you have noticed all influenza viruses have animal names (swine flu, bird flu…) – that is because the virus jumped from an animal to a person.
The World Heath Organization (WHO) is in charge of collecting flu viruses. They culture a bunch of sick people (nasal swab) to find the new and dominant viruses that season. They get pure cultures of the three worst viruses.
Now the magic begins.
Each virus is combined with a harmless standard lab virus. The result is a new virus that looks like the bad influenza virus on the outside, and like the harmless lab virus on the inside. That is important because the human body generates antibodies to the outside of the virus (it can’t see the inside). Now we have a copy of the virus that can’t make people sick, and grows well in chicken eggs. All this happens at the WHO labs.
Next it’s off to the vaccine manufacturers.
This harmless copy virus is injected into fertilized chicken eggs that are 9 to 12 days old. Three days later there are almost countless copies of the virus in the egg white. The virus is then separated from the egg white. Now it’s time to kill the virus with chemicals as we don’t want anyone being infected by this new virus (even though it is harmless). Now the virus is broken up to get a solution of the surface proteins (those on the outside).
This solution, called antigen, is then diluted to the proper concentration for use.
Next, it’s sterilized and packaged in vials and syringes.
There are hundreds of quality assurance tests done at each step of the process.
So your flu vaccine contains just the proteins from the outside of the original bad virus. It doesn’t have the ability to infect you as there is no living virus in the vaccine.
When you get your flu shot, these proteins (antigens) in the vaccine stimulate your body to make antibodies against this interloper. These antibodies will attach to the original virus and destroy it. In about 9 days you have enough antibodies to fight off an assault by the original virus.
It takes six months from finding a new virus to mass-producing the vaccine. That original virus was found in our spring (the Southern Hemisphere’s fall) and is ready for use by our fall season – just in time for flu season.
Producing the new trivalent (3 viruses) vaccine each year is one of the things the human race does very well; it requires worldwide cooperation to pull it off.
So, when you get your flu shot this year (and do it soon to maximize your protection), appreciate the “magic” that half cc of vaccine represents.
It seems most people won’t get a flu shot this year – many turning to what can only be called the Top Ten Flu Myths. Here goes:
2. I won’t get the flu. That is Russian roulette. How often this winter will you be in the same room/elevator/auto with someone who is coughing, sneezing and doing their best to infect everyone? You will find yourself trapped like a rat.
3. I’m healthy, so getting the flu is no big deal. Influenza hits even the strong and healthy like a Mack Truck. Think 104 fevers and every muscle in your body screaming at you. Not much a doctor can do after you have the flu.
4. The Flu vaccine is dangerous. This is the old argument regarding the preservative Thimerosal. There is zero scientific evidence that this preservative is harmful. Given the hundreds of millions of flu shots given, even a tiny risk would be found. If you still fear this preservative, the flu vaccine is available in preservative free form (no Thimerosal) and the FluMist nasal spray has none. For the record, my children, wife and I had the regular flu vaccine (with Thimerosal).
5. Flu shots are difficult to find and useless after November. The flu season changes every year. Things like air travel spread viruses quickly to far flung places. It takes 9 days to develop immunity after being vaccinated. You will still get immunity whenever you vaccinate. In terms of finding the vaccine, the vaccine is plentiful even late in the season. If you decide a flu shot is a good idea, why risk getting the disease for months before getting a shot?
6. I get sick even if I get the flu shot. Influenza takes a couple of days to develop after you are infected. So you can also get exposed a couple of days after the vaccine, but before you are immune. Influenza vaccine doesn’t prevent colds. So any of those situations can lead people to think the vaccine didn’t work.
7. I don’t have the money. A Canadian study found an average savings of $43 in healthcare expense for every vaccinated person. Doctor visits and work absence were all significantly reduced in the vaccinated population.
8. Only old people die of flu. In normal years, 90% of flu deaths are 65 years and over. H1N1 had the opposite with almost all the deaths in the young. It is your contribution to the public good to not be passing around flu this winter. We call that herd immunity. The sum is greater than the parts.
9. I am still immune from last year’s shot. The flu vaccine is redesigned every year based on the early emerging virus types in Southeast Asia (they have their winter during our summer). When we measure immunity, flu vaccine gives very strong immunity for six months or longer. You don’t still have high antibody levels the next flu season.
10. Flu shots hurt. In my clinic, we use #30 needles that are the thickness of a human hair. The vaccine is not irritating to the muscle. There is very little pain with a carefully given flu shot. If you are needle-phobic, you can always take the nasal spray (FluMist).
We have plenty of vaccine, what are you waiting for?