Tag Archives: jerry saliman

Airplane Emergency

by on August 6, 2015

airplane emergency sick

“Is there a doctor on the plane; is there a doctor on the plane?!” The urgent sounding voice rang over the loudspeakers on the jet about thirty minutes into our flight from Frankfurt, Germany to San Francisco. My wife nudged me just as I was trying to arrange my body for sleep in preparation for the fourteen hour voyage. I pressed the call button unsure what emergency I was volunteering for. The next thing I knew I was face to face with the flight attendant who had recently served me orange juice. She explained to me that she was the one who needed medical attention, and she escorted me toward the tail section of the plane where we ascended into a private sick-bay alcove. She proceeded to tell me her story. A year prior to this, she had been hospitalized for a week with a kidney infection, and she was experiencing similar symptoms once again. She had back pain and urinary symptoms, and was desperate for help. I suspected that for her to have been hospitalized for so long previously, the kidney infection must have been complicated by septicemia (bacteria in the bloodstream). When she came to work this day, she had mild urinary symptoms which she thought she could ignore, but now she had a full blown problem. She handed me the emergency medical briefcase that airlines carry onboard, but all it contained were cardiac medicines and injectable opiate analgesics. No antibiotics. What was I going to do to help her? Soon we would be crossing the ocean and there would be no option for emergency landing.

In a New England Journal of Medicine study published on May 30, 2013, it was estimated that there is one in-flight medical emergency for every 604 commercial airplane flights, and overall, there are approximately 44,000 medical emergencies each year world-wide. Serious illness is infrequent, and death rare (3 per 1000 cases). The most common illness causes in order of frequency are fainting and near fainting, respiratory symptoms, nausea or vomiting, cardiac symptoms, seizures, abdominal pain, and infection (such as in my patient). Other in-flight emergencies include agitation or psychiatric symptoms, allergic reactions (better not bring peanuts onboard), stroke, trauma, diabetic complications, headache, arm or leg injuries, Ob-Gyn symptoms, ear pain, cardiac arrest, and lacerations.

You can never be certain that a physician or other medical professional will be on your flight if a medical situation arises. If you feel moderately sick before you start a long airplane trip, chances are that you will feel even worse during the journey so it would be wise to cancel and request a written note from your doctor. If you take medicines, bring them in your carry-on, not in your packed luggage. If you have a past history of a serious infection which required hospitalization, bring antibiotics with you. My flight attendant patient was totally unprepared.

For cardiac emergencies, the airplane I was on was well equipped. There was an automated external defibrillator (AED), oxygen, epinephrine, and a variety of other cardiac medicines. I was dismayed that there were no medicines for infections. In order to help my patient I needed a strong antibiotic that I hoped a well-organized passenger had brought along. I asked nearby passengers for Cipro 500 mg, and fortunately someone volunteered the medicine. All we needed were two doses. Meanwhile, my patient’s kidney infection was causing her significant pain, so I also asked if there was a nurse on board to administer an injectable narcotic. Luckily a kind Kaiser dialysis nurse offered his expertise.

The pilot of the plane spoke to me. We would be flying over Reykjavik, Iceland soon, and this would be our last opportunity for an emergency landing. The pilot put me in touch with a United Airlines land physician in Chicago. I explained to him that everything was under control now that a passenger had donated Cipro. Normally, when one presents to the ER with a serious kidney infection, IV Cipro is administered because it is a faster way to get the medicine into the body. Whether Cipro is given IV or orally, it should have equal efficacy which I discussed with the airline’s physician. I did not think diverting the plane for emergency landing was indicated, and the airline’s physician concurred. During the reminder of the flight I checked my patient every two hours to make sure her vital signs were stable and that she was comfortable. With the help of the narcotic, she slept most of the way to San Francisco. –at least one of us got some rest. – I always feel elated when airplane wheels touch land, and this time I breathed an extra sigh of relief.

I didn’t ask United Airlines for any compensation for volunteering my medical care, but they sent me a $200 voucher anyway. Two weeks later I received a wonderful thank you letter from my patient. It was reaffirming to know that she had completely recovered.

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider

 

 

 

Back Pain – the Bane of Being Human

by on July 7, 2015

back pain pjcc

Back pain can be devastating. Just ask my wife. Prior to our upcoming wedding my wife decided she wanted to get in shape. She joined a gym and, in her zeal, she repeated the weight routine three days in a row. The next day she suffered severe lower back pain which subsequently has besieged her for the past 38 years. (I know this because we just celebrated our 38th anniversary.) Guess who has been destined to be the luggage shlepper and primary grocery shopper in our marriage?

My wife has not been alone in experiencing low back pain. 80% of adults suffer low back pain sometime during their lifetime. In younger people, pain is mostly due to mechanical factors – the interplay of spine, muscles, ligaments, discs, and nerves in the way of they fit together. Low back pain can be triggered by repeated straining such as at a gym, or by a fall or accident, or by a sudden action involving lifting a heavy weight or twisting abruptly. Oddly, a herniated disc can happen spontaneously without a specific injury. In older adults, the most common cause of low back pain is spinal stenosis which means narrowing of the spaces of the spine. With aging, some people develop spurs in their vertebrae, and ligaments around the spine may thicken which together may cause narrowing (stenosis) where the nerves exit the spine. This typically results in pain while standing and walking, and relief by sitting.

Red Flags
While most causes of back pain are not life threatening, there are some warning symptoms that indicate immediate attention is required. These “red flags” include history of trauma, fever, incontinence, history of cancer, unexplained weight loss, long term steroid use, and intense localized pain with inability to find a comfortable position. Coincidently, the reason there why there was a position available when I was hired at Kaiser was because my predecessor had died of back pain due to an epidural abscess, an infection near the spinal cord. While I don’t know the details of his illness, he likely had fever with his back pain, and unfortunately did not appreciate the implication. Life threatening cases of back pain with fever I have treated include pyelonephritis (kidney infection) and endocarditis (heart infection.) Back pain with fever can be a lethal combination.

The inability to find a position of comfort typifies a patient who present with an abdominal aortic aneurysm. For this reason alone, I routinely examine any older patient with back pain for the presence of a pulsating mass in the abdomen. During the course of my career, I have detected two patients with aortic aneurysms. They both were ex-smokers and were overtly grateful since delayed diagnosis is almost always fatal.

A patient with a history of cancer always raises a red flag to me even if the cancer occurred decades prior. The most common types of cancer that spread to bone are breast, prostate, lung, kidney and thyroid. While most doctors have been well educated about not doing unnecessary imaging studies, a patient who has a past history of cancer especially with any history of recent weight loss deserves x-ray evaluation.

When back pain is not spine pain
During the fifteen years I spent working part time in spine clinic at Kaiser, I was amazed the number of times a patient was referred for back pain actually had something other than a spine condition. Two of the most common conditions that can be confused with a spinal disorder especially in older adults include osteoarthritis of the hip and peripheral artery disease (PAD). Hip osteoarthritis can usually be distinguished by performing a hip examination during the visit and by getting hip x-rays. A person with good range of motion of hips does not likely have significant hip arthritis. PAD can usually be determined by checking all the pulses in the legs and feet. The other feature differentiating PAD from spinal stenosis is that patients with PAD do not have pain while standing, while spinal stenosis patients generally do. Sometimes, though, a patient might have more than one condition causing back and/or leg pain in which case more sensitive testing is indicated to evaluate circulation competency and neurological function.

Other causes of low back pain outside the spine include kidney stones, acute pancreatitis, herpes zoster (shingles), endometriosis, and fibromyalgia.

What is the scoop about MRI’s?
A common question from many people with back pain is whether they should get an MRI to pinpoint the cause of their problem. The problem is that most people even without back pain will have an abnormality on an MRI exam. Falsely alarming MRI results in patients who have back pain explain why back surgery in the U.S. is more than twice as high as in other countries. Yes, surgery corrects the problem seen on the MRI but this may be unrelated to the cause of the pain.

Treatment
Treatment of low back pain can vary depending if it is acute or chronic (more than 3 months). There are no hard and fast rules, but generally ice packs are advised for pain within 2-3 days of injury. Heat can help ease subacute or chronic pain. Bed rest after acute injury tends to delay recovery, and it is important to resume normal activity as soon as possible. Physical therapy can help strengthen core muscles that support the spine, but an interesting study from UCLA a few years ago showed that walking three hours a week was more effective than three hours of physical therapy a week. Epidural steroid injections can be given for low back pain associated with sciatica, but a recent NIH study showed that in patients with spinal stenosis who received epidural injections had worse long term outcomes than those who did not receive them. Surgery may be considered in serious injury situations or if there is progressive neurological deterioration. While there appears to be short term benefit in patients who have undergone surgery, long term benefits going out four years and ten years appear to show no clear advantage compared to those who have not had surgery. Although I am not fond of many of the medications advertised for low back pain, sometimes they serve a purpose in helping someone to become more active and exercise once again.

Prevention
Regular exercise is the best way to keep one’s back healthy. My wife has found walking at least 60 minutes a day helps to lessen recurrences of low back pain. She also stretches regularly, and does not wear high heeled shoes. When she is sitting in the car or a chair, she uses a lumbar support called a Sacro-Ease or an inflatable travel pillow. She avoids any significant lifting, but if she does lift something she lifts with bent knees, carries the object close to her, and does not twist. For me, running, biking, and doing yoga at the PJCC keeps my back in shape, but everyone has to find a regimen that works best for them.

Conclusion
While back pain can be disabling, it can also be managed with regular activity and awareness to prevent further damage. Three months ago my wife injured her back again when she missed a step getting out of an elevator while holding one of our granddaughters who impeded her vision. To avoid trauma to our granddaughter, she sacrificed herself by intentionally twisting her spine as she fell. I am happy to say that granddaughter and “Nana” are back in each other’s arms once again.

For further information about low back pain, visit the NIH site.

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider

 

 

The Meaning of Life – As Seen through The Eyes Of My Patients

by on September 3, 2014

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As we approach the High Holidays of Rosh Hashanah and Yom Kippur this month, I find myself becoming more reflective, particularly about what’s important in my life. Twenty years ago I was asked to complete a biographical survey for a physician newsletter about my personal interests, which included questions such as the latest book I read, my favorite movie, etc. There was one question that stood out, “What is the meaning of life?” My response, “God knows.” It occurred to me a few years later that I could delve into a better understanding of this existential question by probing my patients for their stories about what has been meaningful in their lives. You may wonder how during a 15-20 minute visit with patients I could have time for such a discussion. One cannot come out and say, “Tell me the meaning of your life,” but I felt I could approach the Continue reading

High Blood Pressure – The Hidden Killer

by on August 5, 2014

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On April 12, 1945, President Franklin D. Roosevelt was sitting in his living room having his portrait painted by artist Elizabeth Shoumatoff, who later became most renowned for “Unfinished Portrait” of FDR. Also present was Lucy Mercer, Eleanor’s social secretary, but most notorious because of her affair with the president. His dog, Fala, and two cousins were in the room as well according to biographer Doris Kearns Goodwin. At 1:00 pm, FDR complained of “traffic pain at the back of my head,” and collapsed, unconscious. His cardiologist quickly arrived and recognized the signs of a cerebral hemorrhage, a type of stroke. One could argue that one of FDR’s visitors that day triggered his stroke, but it is much more likely that years of untreated high blood pressure led to FDR’s demise at the age of 63.

High blood pressure or hypertension still remains a hidden killer at large. It is estimated that high blood pressure kills approximately 1000 Americans each day due to its effects on Continue reading

Bone Up!

by on March 4, 2014

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On May 12, 1990, I was speeding on my mountain bike down an unfamiliar mountain trail.  All of a sudden, the trail veered sharply to the left while I kept going straight. I went flying over a short wooden fence down a steep mountain hillside, and rolled and tumbled like I was in a bad dream.  When I finally came to a stop, I was surprised I was still conscious.  My bike helmet and glasses frame were cracked, and with the awareness of sharp pain emanating from my left wrist, I feared my wrist was cracked too.  After I was transported to the ER, I found out that I had a broken wrist bone and derangements of the surrounding ligaments.  I needed to have surgery if I was ever to play the violin again.
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