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Hernias

About two weeks ago I’m on one end of my mother’s piano trying to horse it up the ramp into the moving truck.  First my back starts to feel not so good.  Then I notice down near my groin isn’t feeling just right either.  I figured I’d just strained something a little.  But now it’s not going away.  When I walk or lift or cough or even stand for a while it starts talking to me down there.  And I think it’s a little swollen or something.

A hernia is the protrusion of an organ through the wall of the cavity that normally contains it. In the case of an inguinal hernia, which this man had, a loop of intestine pushes from the lower abdomen down toward the groin (toward the scrotum in males).

Any young man who has been involved in school sports and has had a sports physical is aware of the “turn your head and cough hard” part of the exam where the doctor checks for an inguinal hernia.  Usually the symptoms are either a bulge along one side of the groin or pain in that same area, or both.  Inguinal hernias make up over 75% of all abdominal hernias and they are almost 10 times more common in males than females.  The rest of abdominal hernias are made up of umbilical hernias (a hernia at the belly button), femoral hernias (slightly lower than the inguinal hernias and almost exclusively found in females), incisional hernias (at the site of past surgeries), and a small number of other less common hernias.

Inguinal hernias are sometimes found at birth and are particularly common in premature babies.  Overall, they occur in about 4% of babies, while umbilical hernias occur in about 17% of newborns.  Inguinal hernias in babies need to be repaired to avoid the 10-20% chance of strangulation – a complication in which the blood supply to the loop of intestine contained in the hernia is cut off causing that part of the intestine to die if surgery is not done right away.

Umbilical hernias in newborns have a more benign outcome with the vast majority closing before age 3 to 5.  If they do not close by this age they can be surgically repaired.

In adults the picture is a little different.  Risk factors for hernias in adults include heavy lifting, overweight and obesity, straining at bowel movements, and chronic cough.  If a new bulge or pain occurs in the groin or abdomen, a physical exam by a doctor can usually diagnose whether a hernia has occurred.  Rarely, imaging is called on to verify or rule out a hernia.

The chance of strangulation is lower in adults.  For this reason, if a hernia is painless some adults choose to take a wait and see approach rather than get surgery right away.  Of course the hernia won’t ever go away without surgery; exercises and trusses and supports don’t repair the defect.

If surgical repair is decided on, the surgeon can give the pros and cons of an open repair vs. laparoscopic (where a scope is used, allowing for smaller incisions and a quicker recovery).  Although it varies, one can usually count on 4-6 weeks of avoiding vigorous physical activity after an open repair, and perhaps half of this time if laparoscopic repair is done.  The surgery itself is usually a day surgery except in complicated cases.

One last common, but somewhat different, hernia is a hiatal hernia.  These can’t be seen from the outside but usually are noticed on an upper GI study or occasionally on an x-ray. A hiatal hernia is where a portion of the stomach pushes up through the diaphragm, usually at the opening through which the esophagus passes.  They are very common occurring in over 60% of individuals over 50 years old.  Ninety percent of them give no real symptoms but about 10% give some increased heartburn, indigestion or upper abdominal discomfort.  If these symptoms occur, an acid blocker such as Prilosec or others is usually helpful.  Very rarely a surgical repair is carried out for an unusually symptomatic case.

But back to the common groin hernias, if you have a tell-tale ache or bulge, you know the drill: see your doc, turn your head and cough.

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Lessons Learned in Haiti

Does anyone have any questions?” I am standing inside an 8 foot by 8 foot corrugated metal shack with a fabric roof in Port-au-Prince, Haiti.  It is stiflingly hot with not a breath of wind.  It’s hard to imagine spending a half hour sweating inside this metal box let alone living there.  But it is the home of a single mom who is resolutely raising her daughter with a little help from her church (whose pastor has asked whether we have any questions) which is in turn helped a bit by an American church.  But there is no mistaking that if there is a hero in this little room it is this uncomplaining resilient mom.

Unable to think of what to ask I just inquire whether the fabric roof keeps off the rain when it comes.  Through the interpreter, the mom responds with soft strength, “We do fine when it rains; we are OK.”  And she smiles with her arm around her daughter’s shoulder.  Honestly my gut instinct is to bow at her feet, to somehow honor her.  Instead I merely tell her it was so very good to meet her, and head back to our vehicle.

Over the next two days we see several hundred Haitian children and adults for a range of medical problems.  Most of them are caused by their environment: parasites from contaminated food and water, anemia and nutritional problems, neck and back problems from the loads carried on their heads, eye irritation from the dust and headaches from the heat.  We give medicines to treat the parasites, knowing that they will be re-infected by the same food and water in a matter of days.  But at least we can knock back the body’s burden of parasites temporarily and allow them to rebound a bit nutritionally.

The chronic problems like diabetes and high blood pressure cannot be adequately addressed.  The numerous blood pressures in the 200’s over 120’s or 130’s that would punch a ticket to the ER in the states, can only be given a short supply of BP meds with the advice to be sure and see another doctor before they run out.  But the odds are hundreds to one against that happening.  There is no access and no money for such things.

And so we put the equivalent of band aids on gaping wounds because it’s all we have, and hope that the brief attention given them brings some bit of comfort.  They are amazingly grateful.  The rest of the team prays with them, gives the children balloon animals that light up their faces and generally tries to minister and encourage.  In the end we hope we have left some small drops of blessing in this ocean of need.

What have we taken back?  A conviction that we need to complain far less and give thanks far more.  We also understand that we cannot fix the whole of Haiti, or even this little section of Port-au-Prince.  Yet, through this church in Haiti that ministers to and knows these families, we, as representatives of our church can minister to twenty orphans and vulnerable children.  They are given help to attend school, eat a good lunch, live within a family setting, and get to know the God in whom they find ultimate hope.  The group facilitating these church to church connections is World Orphans, a ministry that has earned its stripes over many years and has become wise in a type of helping that really helps. This steady life-on-life help and attention over many years, given by those who know and love these children best is where there is hope for at least some in Haiti.

In all this I am reminded of the quote by Edward Everett Hale, “I am only one, but I am one. I cannot do everything, but I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.”  We got to do something for a short time in Haiti.  A Haitian mom, uncomplaining in her small metal shack, continues to do those things she can do every day to see her daughter grow up strong.  In my mind I still bow at her feet.

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DPC: Subtracting the Guesswork and Adding Back the Relationship

This week my partner, Jackie Hone, was seeing a new patient who had driven an hour seeking her help in sorting out his health situation. She spent an hour seeking to undo the damage done by miscommunication from multiple encounters in varied medical settings. Her patient had been left confused, upset, and almost ready to give up. He was uninsured and prior to his current problem had been quite healthy and had no primary care physician. But following his recent shoulder surgery he experienced a concerning post-operative symptom, was sent to one ER, transferred to a second hospital, had his diagnosis changed several times, was admitted for a 4-day hospital stay, and was finally discharged still lacking a definite diagnosis, plan, or prognosis. Of course his medical bills are staggering from all of these encounters. He was left pondering, “If medical care costs so much, why is it so poorly delivered?”

Most of us somewhere along the way have had a frustrating medical experience: maybe we received only a fleeting explanation about a procedure, medication, or treatment being recommended. Or perhaps we received a surprisingly huge bill after the dust settled on our medical care. Or we had follow-up questions but couldn’t reach anyone to answer them. Maybe all of these. So, is that just the way it increasingly has to be, or is there a better way?

Having a relationship with a physician who knows us in times of health and sickness is valuable. Likewise having a doctor who can be reached in an emergency is huge. And having a physician’s office that can help us navigate complicated medical tests and specialists to anticipate and manage costs is something for which most can only wish. But maybe these things are not impossible to achieve.

My partner and I believe that a return to direct agreements between doctor and patient is the first step toward providing this experience as the new normal in primary care. I am referring to the medical care model known as Direct Primary Care (DPC). It is so named because patients deal directly with their doctor to form an agreement defining what services and care will be provided for a known and affordable monthly membership fee, rather than billing for services through the middle-man of insurance. One recent joiner to DPC had calculated that his medical cost for primary care would only be about 30% under DPC compared with what he had paid for primary care coverage by insurance the previous year.

Now that Dr. Hone has been practicing a DPC model for the past seven months, we can report that patients in this model are very satisfied with their care, are able to communicate efficiently with our office, and can be seen when needed. Their visits are not so rushed, their wait times have been reduced, and cost is highly affordable due to the reduced overhead from not having to jump through the countless hoops of insurance companies.

The basic fee, not much different than a cell phone contract, covers all basic primary care including normal labs, physicals, maintenance visits and sick visits. Any procedure or lab not included in the membership agreement is offered at a low cost compared to insurance rates, and is discussed in advance with the patient. The lower patient volume in DPC allows more “face time” with patients which translates to better communication all around, the chance to be heard by the doctor and ask questions, and the efficiency of handling more than one complaint at a visit. Because payment is based on a monthly fee, rather than an office visit, communication by phone and email is welcomed rather than discouraged (as it often is in an insurance-based model). Finding the right catastrophic coverage that provides for unforeseen emergencies, imaging, or specialists, is important to complete the picture.

Of course there are still a few folks who have great insurance and may not need Direct Primary Care to help healthcare be affordable and personal. But for many patients we have found that it works wonderfully, saves them time and money, and improves their overall healthcare.

In light of all this Dr. Hone and Trinity Medical are celebrating the Grand Opening of her new office next to Sonic at 1515 E Lamar Alexander Parkway on Thursday, August 11th from 11:00-1:00pm. If you have a few minutes, check it out and find out a bit more about how Direct Primary Care really can be a better way.

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Sore Throats – More Complicated Than You May Think

I returned to the exam room with the results of the five minute rapid strep test on an elementary school boy whose mom had brought him in with a complaint of a very sore throat.  “His strep test is negative Mrs. Thompson.”

Well that’s a relief!”

My own thoughts about it were a little more mixed.  Most of the non-strep throat infections are viral so you are left to just letting them run their course.

Pharyngitis is the medical term for infection or inflammation of the throat, generally causing the symptom of a sore throat.  The problem is, someone with a bad sore throat is usually hoping for antibiotics to help them get better.  In fact up to 70% of patients going to a doctor for a sore throat (and there are about 15 million people in the U.S. who see the doctor for a sore throat every year) receive antibiotics.  At the same time, only about 20 to 30 percent of children and just 5 to 15 percent of adults with a sore throat have strep.  Most of the rest have viral infections where antibiotics only contribute to side effects and more resistant infections, while providing no benefit..

So how do we sort out which infections are strep and which are probably viral?  First there are other symptoms that help greatly.  If there is a runny nose or cough with the sore throat it is almost certainly viral and not strep.  A classic strep throat has fever and sore throat without runny nose and congestion, but often with nausea or headache.  Also, age matters: strep is uncommon under 3 years of age, peaks between 4-7 years of age, and becomes less common in adults, though still showing up sporadically.

It has been shown repeatedly that even experienced doctors can’t reliably tell a strep pharyngitis from a viral one just by looking – there is too much cross-over in how they appear.  So a rapid strep test really is needed for accurate diagnosis.  These are up to 90-95% accurate and only take a few minutes.  Recently it has been recommended that the old routine of double-checking a negative rapid strep test with a throat culture be abandoned as it adds cost without any measurable additional benefit.

Here is a question that is not as obvious as it first appears: why do we even want to treat strep throats with antibiotics.  It surprises most people to hear that strep throat will usually clear up in a few days (about 7 days on average) even without antibiotics.  The benefits of the antibiotic (usually penicillin unless a person is allergic to it) are that they:

  • Slightly shorten the course of the infection (by 12-16 hours)
  • Render the person non-infectious more rapidly (usually within 24 hours of starting the antibiotic)
  • May minimally reduce complications such as abscesses of the tonsils or ear infections
  • May possibly help prevent serious other complications of strep pharyngitis. But this is controversial as they have never been proved to prevent the kidney disease called post-strep glomerulonephritis. Likewise many argue that rheumatic fever (a serious complication permanently damaging the heart) doesn’t seem to be caused by the vast majority of the strains of strep currently occurring in the U.S.

So the benefits of antibiotics for treating strep throat are sketchier than they were once thought to be.  And on the other side of the coin, about 10% of those treated with antibiotics get diarrhea, occasionally a serious type caused by C. difficile.  Also 0.24% have a life-threatening allergic reaction. This means that out of 10 million patients treated with antibiotics, as many as 24,000 of them will have fatal or near-fatal allergic reactions.

Most sore throats get better without treatment, even including strep pharyngitis. So the decision to test and treat is a bit more complicated than it was once thought and deserves some individual thought on a case-by-case basis.  As a little side note, that’s why the emergence of telemedicine (where patience are diagnosed and treated by phone) holds as much concern as promise. The tendency to misdiagnose illnesses and misuse prescriptions will only grow with this looser connection between patient and physician.

So who thought something as “simple” as a sore throat would take two articles just to summarize?  But we haven’t even mentioned mono or the non-strep bacterial culprits that can be other serious causes of your sore throat.  More on that next time.

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