Bruises

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Hi everyone, It’s Dr. Rob and this is the House Call Doctor’s Quick and Dirty Tips for Taking Charge of Your Health. 

I have good news regarding today’s podcast: the subject comes from a genuine living human being.  Last week I had to rely on Ralph, an imaginary person to supply my subject material.  While imaginary friends have their advantages over real humans, I have yet to care for an imaginary patient.  They are all real.  When I do see an imaginary patient, I will be sure to let you know.

What are Bruises?

This actual person is named Emily, and she asks me the following:

“Dr. Rob, can you tell me about bruises?   What should I do when I get one?  And why do they itch?  I’ve always wondered about that.”

The medical term for a bruise is hematoma.  Bruises happen when part of the body encounters blunt trauma. You can find good examples of blunt trauma every week on the popular TV show America’s Funniest Videos.  On the show, people receive blunt trauma in amazing ways and usually in very unfortunate places.  Doctors call blunt trauma to the human body a contusion. AFV is accurate, though, as scientists estimate that 25% of all contusions happen when people stand too close to a piñata.

What Causes Bruises?

So what happens after the cameras stop rolling? The blunt trauma to the unfortunate body causes small blood vessels under the skin to break, letting the blood seep into the surrounding tissue.

Before moving on, I need to mention that that bruises don’t just happen to the skin.  You can bruise a bone, your liver, or your brain.  The mechanism is the same, blunt trauma leading to blood seeping into the tissue of one of these organs, but it can obviously be more serious.  It also has a better chance of winning the $10,000 prize.

So what happens after the blood seeps into the soft tissue?  The red blood cells break and spill their insides out into the surrounding tissue.  The most significant substance from inside the red blood cells is called hemoglobin.  Hemoglobin is the protein that makes blood red.  In the bloodstream, it binds to oxygen and carries it from the lungs to the parts of your body that need it.  Hemoglobin that is bound to oxygen is bright red, and turns darker and bluish in color when it loses the oxygen.  That is why the veins under your skin are blue -- they are the thinner-walled blood vessels that take the blood back to the lungs after the oxygen is taken off.

Why Do Bruises Hurt?

When the red blood cells break open, they release substances that signal the body to bring in the white blood cells.  The white blood cells are the paramedics of the body, but instead of using teeny little stretchers, they actually eat the hemoglobin and other things let out by the broken red blood cells.  Any paramedics listening to this podcast shouldn’t get any ideas from this.  The white blood cells then release more substances that cause the swelling and redness known as inflammation.

Inflammation is what makes the bruise hurt so dang much.  The redness and swelling are from the increased blood flow that occur to speed the healing.  The pain serves to remind the injured person to steer clear of situations that could cause additional trauma.

Why Do Bruises Turn Colors?

You may have noticed that bruises go through a series of colors before they go away.  Maybe you haven’t noticed this, but you have to trust me on this one.  If you still don’t believe me, find the nearest piñata, blindfold a kid, and stand real close.  You’ll soon have a hematoma of your very own, and you’ll see I speak the truth.

The colors of a bruise appear courtesy of proteins being broken down inside the white blood cells.  The first color is purple, which is caused by the hemoglobin being broken down and losing its oxygen.  That happens immediately after the injury and persists until all of the hemoglobin is broken down. The purple part of a bruise is called ecchymosis. 

Let me pause now to take a moment and personally thank whoever made up the word ecchymosis. It is definitely on my top-ten of medical words, and is very handy at parties when you want to impress people.

Not that I would do that.

The first breakdown product of hemoglobin is called biliverdin, which appears within a few days of the contusion.  Please don’t confuse biliverdin with Billy Virdon, who was manager of the Pittsburgh Pirates in the 70’s.  To my knowledge, Billy Virdon never seeped into soft tissue only to be eaten by white blood cells.  Let’s hope not.  Biliverdin is green, a color that can sometimes be seen in bruises.

The green biliverdin is then converted to a yellow molecule called bilirubin.  That process takes anywhere between a few days and several weeks, depending on the size of the bruise.  Once bilirubin is made, it dissolves in the blood stream and is carried off to the liver and kidneys for final processing and excretion. (Is this when the bruise becomes finally healed?)

Some listeners may recognize bilirubin as the substance that causes many babies to turn yellow not long after they are born. That is called jaundice, and happens to babies when their bodies break down special red blood cells they need before they are born.  There are other causes of jaundice, but I’ll leave that for another podcast.

Why do Bruises Itch?

Which brings me to the question that has kept Emily up at night for all these years: why do bruises sometimes itch?  While I couldn’t find a definitive reference on this, I have a pretty good guess.  One website I found suggested that histamine (one of the substances released to cause inflammation) is the culprit, but that happens early in the process -- not the time when most of the itching occurs. 

I think the itch is caused by bilirubin.  It is well known that elevated bilirubin levels can make a person’s skin itch (although it’s not clear why it does).  It seems reasonable to me to conclude that the bilirubin produced by a maturing bruise is the source of the itch.  That’s my best guess.  If anyone can find a more definitive explanation, please send it my way.

Tips For Bruises

Now that you know about what causes bruises, here are my quick and dirty tips on how to deal with bruises.

Tip #1 - Stay away from piñatas

This is self-explanatory.

Tip #2 - Don’t worry about small bruises 

Bruises are just part of the body’s process of fixing itself when things get messed up.  They shouldn’t be thought of as something bad, but rather just a part of healing.  Putting ice on a bruise and taking anti-inflammatory medications (like ibuprofen) can make the pain less, but isn’t necessary unless the bruise is large.

Tip #3 - Consult your doctor for large bruises 

Large bruises generally come from bad injuries.  Bad injuries don’t always look bad from the outside, hiding the presence of serious problems.  Large bruises can also cause a person to become mildly jaundiced and even cause fever.  Your doctor can make sure you don’t have internal damage and can help you minimize your pain.

Tip #4 - Seek attention for bruises in certain places

Be careful with bruises on your neck.  Neck bruises can compress your windpipe -- even if they don’t look serious from the outside -- and make it difficult to breathe. 

Bruises on the nose and ears cause other problems.  These structures are comprised of cartilage, which can be damaged significantly in the presence of a bruise.  This can result in significant deformity of the nose and ears – something that could threaten your modeling career.

But a hematoma on the head, or a goose egg, is actually not as bad as it looks. These bumps can appear suddenly and can look impressive, but they really aren’t usually that serious.  Bruises on the skull have no way to go but out, and so pop out quickly.  The presence of a goose egg by itself is not a reason to go to the doctor.  Instead look for changes in mental status or loss of consciousness, which could indicate bleeding into the brain.

Tip #5 - Seek medical attention for bruises that occur without injury or multiple unexplained bruises. 

Bruises on your back and bruises that appear without cause can be a sign of a serious problem.  Treatment with medications like aspirin or other blood thinners can be the cause of bruises like this, but so can diseases that compromise the blood’s ability to clot.  If you are worried about bruises like this, go to your doctor to make sure it is nothing serious.  It is far better to overreact than to stay at home with a serious problem. 

Tip #6 - If you get it on film, you could get it in cash

Antibiotics

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Hi gang!  (Cough, cough) This is Dr. Rob, and this is The House Call (cough) Doctor’s Quick and Dirty Tips for Taking Charge of Your (cough) Health.  Sorry about that.  I’ve been coughing like this for a few days.  I’ve even had some fever.  I wonder if I may need an antibiotic!

(Buzzer Noise)

Wrong answer!  I get people coming into my office with many of the same thoughts.  But they aren’t just wrong; they could actually be hurting themselves.  The proper use of antibiotics is a very important subject for everyone to understand; so that is what I will cover in today’s podcast.

What are Antibiotics For?

First let me explain what antibiotics do.  Antibiotics treat infections.  Infections are the invasion of your body by teeny-tiny bad guys called germs.  The two main kinds of germs are bacteria and viruses (although fungi can be pretty bad dudes as well).  

These bad guys don’t wear stockings over their heads or bandanas over their mouths, but they do try to sneak in without being seen.  Why are they so set on getting into your body?  Simple! They want to eat and make babies.  Really.  Your body is warm and full of water and food needed to do this.  It’s a veritable land flowing with milk and honey.  So they do what it takes to get in.

OK, so what’s so bad about that?  They just want the freedom to do what we all want to do, right?  Live and let live.

Bacteria and Viruses: the Good and the Bad

Some bacteria and even viruses aren’t bad.  They wipe their feet and make sure they follow the local customs.  Some bacteria even benefit us, and we become sick when they are not present.  But other germs are pretty rude guests.  They take food that is not theirs, leave their waste all over the place, and generally wreak havoc.  They even sometimes release toxic pollution and sometimes make so many babies that they kill off the person whose place they crashed.

Sigh.  Oh, how I wish instead that they’d join hands with us, share the food, and sing Kumbaya.  It’s a hard world we live in, folks.

How Your Body Reacts to Infections

Fortunately, your immune system is really good at knowing which guests will follow the rules and which ones are bad news.  It’s the job of certain white blood cells in your body to police the areas where germs hang out, making sure they regret their decision to make you their home.  They either kill of the germ themselves, or they take a picture of it and circulate that picture around the rest of your body -- kind of like those pictures of people in the post office.  No, they aren’t actual photographs, they are special proteins called antibodies that carry the image of the bad guys around for all to see.  So the next time the germs try to get in, antibodies grab them, which is a signal for the white blood cells to come kill the offending germ.

So what does this have to do with antibiotics?  Well, remember those really bad germs I told you about that make so many babies and put out so much pollution that they kill their host?  These germs are especially good at avoiding the post offices, sneaking around in shadows, and giving the white blood cells the slip.  That is when infections like pneumonia and meningitis can cause problems. Antibiotics were made to help the body fight off these crafty little buggers so they can’t do their damage.  Their invention prevented millions of deaths from infectious diseases.

So What’s the Downside?

Antibiotics of sorts have been around for thousands of years but only came into widespread use in the early 20th century.  Prior to antibiotic therapy, simple infections like bladder, ear, and sinus infections could potentially become life threatening.  So when antibiotics became available, they were used with abandon.

But something happened.  Each infection contains a gazillion bacteria (they are really, really tiny) and while the antibiotic kills off almost all of them, some are mutants (kind of like the X-Men, only evil) and can resist the deadly antibiotic.  Fortunately, the white blood cells arrive on the scene, clean things up, and send out antibodies to go up in the post offices and do their noble duty.  Some of these mutants, however, hide in the shadows.  They lurk in places where they can’t be seen, waiting to get their revenge.  They don’t make babies, they just lay low and bide their time.

Mutant Bacteria

Eventually, mutants from different people join forces with each other.  The more antibiotics are used, the more mutants survive, team up, and they finally create armies of resistant mutant bacteria.  They are not scared of antibiotics; they scoff at the puny threat of these once deadly drugs.  They probably have a little high-pitched evil laugh, but I’ve never heard one. 

But seriously, they really are mutants.  I am not just saying that to keep your interest.  The emergence of resistant bacteria in this way has gone on since antibiotics were first used.

To deal with these mutant armies, we humans created new antibiotics that would counteract the resistance strategy of the bacteria and kill off the mutants.  But guess what happened then?  You got it: more mutants; but this time they’re even more resistant and difficult to kill.  And so the cycle went on for a good portion of the last century: the good guys would make stronger weapons, and the bad guys would figure out a way to resist them. 

When will the madness end?  Unfortunately, we were the ones to run out of solutions.  Now there are bacteria out there that are resistant to nearly every antibiotic made.  It’s a scary thing.

Why this Happened: Overuse of Antibiotics

One thing that contributed to the emergence of these evil mutant bacteria criminals was the overuse of antibiotics.  Antibiotics are only good against certain infections.  The antibiotics most people know--penicillin, sulfa drugs, erythromycin, to name a few -- are weapons aimed at bacteria.  Viruses are totally different than bacteria, and so are not vulnerable to these medicines.  They thumb their little noses at them.

Viral Infections Versus Bacterial Infections.

Virus infections are very common, and most of them are pretty wimpy.  They cause cough, runny nose, and maybe a short case of the runs -- not exactly a fun frolic, but not deadly.  The virus infections that cause respiratory symptoms like stuffy nose and cough cause the body to put out a lot of mucous.  Unfortunately, the mucous is like an all-you-can-eat buffet for some bacteria.  If mucous builds up in the sinuses, bacteria can creep in, take up shop in there, and cause the infection called sinusitis.  In the same way, mucous in the ears can lead to bacterial ear infections, and lung mucous can turn into pneumonia.  These bacteria are much worse guests than the viruses, causing pain, fever, and more serious complications.

But it’s sometimes hard to tell a bacterial from a viral infection, and so doctors figured it was better err on the side of caution and gave antibiotics to people with virus infections.  Guess what happened to those people?  They got better!  People get better from virus infections without treatment, but if they are on an antibiotic they tend to think the antibiotic made them better.  The antibiotic wrongly gets the praise for the job that the immune system did.  Poor immune system, nobody ever appreciates it!

So what happens when the person gets their next viral infection?  They run to the doctor and say, “Hey doctor guy!  The wonder drug you gave me last time made me better, and I want it again!”  The doctor, wanting to please the patient, gives another antibiotic prescription.  They what happens?  Bingo!  The person gets better again!  That cycle was repeated again and again for many years in many doctors’ offices. 

Including mine.

Yes, I gave into that pressure.  I have to tell you, getting that off of my chest makes me feel much better.  Thanks for being there for me.  When I first became a doctor (not long after Columbus discovered America), I really wanted my patients to like me.  I was a little insecure that nobody would want me as their doctor-- or if they did-- it would only be when they had no other option.  It’s common for young doctors to want to impress their patients, and even more common for them to want to avoid making their patients angry.  So even though I knew most infections were viral and did not need antibiotics, I caved to the desire to please patients.  It was hard not to because many of them were really sure they needed antibiotics.

It’s not as big of a battle anymore.  Part of this is that I’m an old fart now and don’t mind making people mad at me.  I’ve got plenty of patients and don’t need to practice bad medicine to keep my office full.  Another factor is the fact that big bad resistant bacteria like MRSA have made the news.  People are finally aware of the harm of antibiotic overuse, and so will crumple when I say something like: “I certainly don’t want to use antibiotics if they aren’t needed.  I don’t want to create resistant bacteria.” 

Now What?

But the damage has been done, and now we really have nasty mutant bacteria armies causing havoc in certain places.  Some have even referred to this time as the post-antibiotic era.  I wouldn’t go that far.

The good news is that not all mutations make bacteria stronger.  What caused the creation of antibiotic-resisting super bacteria in the first place was the presence of antibiotics.  If a population of resistant bacteria is left alone, the need for this antibiotic-resistant trait disappears, and eventually fat and lazy bacteria without the resistant genes replace those nasty resistant bacteria.  I’m sure there are old resistant bacteria that say something like: “I remember back in the amoxicillin era, bacteria were dying left and right.  Kids these days don’t think resistance is important.  Bah!” 

The moral of the story is that the more you use antibiotics, the less they work; but the less you use them, the more they work.  But here’s the catch: that rule only works well when everyone everywhere follows it, as the bad bacteria off of your uncle Fred who overuses antibiotics can jump on you and make you sick.  We all have to be careful to avoid overuse. 

So when are antibiotics needed and when should they be avoided?  Here are my quick and dirty tips about antibiotics:

Tip 1: Wait

I have people coming in to see me who say: “The last time I got a cold, I got a sinus infection.  I want to catch it now before it goes into one.” 

While I appreciate their desire to avoid getting sicker, creating resistant bacteria is a much bigger risk.  Even if there is a 50% chance it will turn into an infection needing an antibiotic, waiting until the illness declares itself is always the best policy.  If I give antibiotics when you don’t need them, then they may not work when you do need them. 

Tip 2: Wait Some More

I prefer waiting for a week before I treat cough or sinus symptoms.  Studies show that people do just fine waiting.  But don’t antibiotics make bacteria infections get better faster?  The truth is, most bacterial ear infections and sinus infections will get better without antibiotics.

Don’t believe me?  In one study of children with ear infections, parents were given pain-relief eardrops and a prescription for antibiotics and told to delay antibiotic use.  Over half of these children didn’t end up needing an antibiotic, and they had less bad symptoms than the antibiotic-treated kids, many of whom had antibiotic side effects.

Other studies have shown that real sinus infections got better just as fast without antibiotics as they did when antibiotics were given. To be honest, a lot of prescribing is still done more out of tradition than scientific fact.  It’s hard to break old habits.

My point is this: if you don’t feel too bad, wait.  Don’t see antibiotics as your only hope; see them as the last resort.

Tip 3: Use Other Treatments

Have you ever noticed that fast-moving streams are generally clear, while water that doesn’t circulate has stuff growing in it almost immediately?  The same thing is true with mucous.  One of the reasons your body puts out mucous is to flush out the respiratory tract and keep infection from coming.  Using treatments that keep mucous flowing can prevent bacteria from moving in.  Here are some ways to do this:

  • Drink lots of liquids.  You have to stay hydrated to make mucous.
  • Humidify.  Use of humidifiers, hot showers, and saline nose sprays can keep mucous flowing. 
  • Irrigate.  Some people enjoy pouring large amounts of fluid in their nose, but most of us are a little squeamish about nasal irrigation.  It really works, but I don’t blame you if you take a pass on this one.
  • Medicate.  Expectorants like guiafenacin, which is found in Mucinex and Robitussin, can break up phlegm.  Decongestants can open up the sinuses and allow flow.

These treatments aren’t foolproof, but they can prevent some infections and they can make you feel better.

Tip #4: Contact Your Doctor if You Are Not Sure

Tell your symptoms accurately and express your concerns.  Most doctors will listen to their patients and give antibiotics when appropriate.  Remember, it’s much easier for the doc to give in and prescribe than it is for them to wait.  Ask lots of questions and make sure you know what to watch out for when you leave. 

Don’t get upset if you don’t get an antibiotic.  I’ve had patients say that I “didn’t do anything” for them if I didn’t give an antibiotic. But not giving an antibiotic doesn’t mean I don’t thing the patient is sick, and I need to communicate this.  I have to give the person things to do so they can feel better and give them an idea when they would need to call back.

It’s not a waste to come in for this kind of thing.  It’s better to come in and find out you have nothing serious than it is to stay home when you need to go in.

Tip #5:  Know Warning Signs

There are some things that should alert you of danger, which means you need an immediate trip to the doctor.  Here are some of them:

  1. Fever and a stiff neck, which could mean meningitis
  2. Cough, fever, and shortness of breath, which could be pneumonia.
  3. Sore throat and a high fever, which could be strep.  Strep’s not a terrible infection, but untreated it could lead to more serious complications.
  4. Persistent or severe abdominal pain , which could be appendicitis, gall bladder infection, or other serious problems.
  5. A fever over 102. Fever doesn’t cause harm by itself, but a high fever may indicate the presence of a more serious infection.  It’s worth getting checked for this just in case.
  6.  Finally, really young and really old people should be treated with caution.  The “Wait” rule doesn’t apply to infants under 4 months or frail elderly people.  Be very cautious with these and other frail people.

That’s it for today’s extended podcast (sorry it went long).  I didn’t intend that it be the final say, but I hope you now understand why sometimes it is better to wait than to run to antibiotics.

Acetaminophen (Tylenol)

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Hi again!  This is Dr. Rob, and this is The House Call Doctor’s Quick and Dirty Tips for Taking Charge of Your Health.

I am sure a lot of you have heard about the recent warnings regarding acetaminophen, the ingredient found in Tylenol. It seems like nearly every medicine we thought was safe ends up being dangerous, doesn’t it?  In this podcast I will explain the dangers of this drug and safe ways to use it.

FDA Recommendations for Tylenol

For those of you who did not hear the news, here are the FDA recommendations for acetaminophen:

  1. All acetaminophen products should be clearly labeled with a warning of the risk of liver damage.
  2. The warning should also mention the danger of moderate alcohol consumption with this drug.
  3. There are many medications that contain acetaminophen in combination with other drugs; these should be clearly labeled as containing acetaminophen.
  4. Acetaminophen is an important medication and should not be taken off of the market.

What’s the bottom line?  Acetaminophen is very safe if taken appropriately, but very dangerous if taken in large amounts.

Acetaminophen is Dangerous

Acetaminophen is the number one cause of liver failure in the United States.  Each year thousands of people need treatment for liver damage related to this drug, and hundreds of people die due to liver failure from taking too much of it.  There are three main ways people put themselves at risk:

1. Intentional Overdose 

Two of my saddest moments as a doctor have been because of acetaminophen overdoses.  I have seen two young people who took large doses of it as suicide gestures. Neither of them was really trying to kill themselves; they took it because they thought it was safe.  It’s just Tylenol; it’s not dangerous.  Unfortunately, neither realized the danger until it was too late. Both of them died because they didn’t seek help in time.  I really believe that proper labeling and education might have prevented these tragic deaths.

2. Combination Drugs

The second way people get too much is by taking it along with combination drugs that contain acetaminophen.  Many common pain medicines contain acetaminophen along with a narcotic.  Common examples include:

  • Vicodin
  • Percocet
  • Lortab and Lorcet

There are also common non-prescription drugs containing acetaminophen. Here are some examples:

  • Nyquil
  •  Theraflu
  • Excedrin
  • Contac

I’ll post a link to a list of these drugs in the show notes.  Look for “cet” at the end of the name or the letters “APAP” on the label, as they often indicate the presence of acetaminophen.

3. Alcohol and Liver Disease

Finally, people who drink more than two drinks per day, and people with liver disease should be very careful taking acetaminophen.  Alcohol is also toxic to the liver, and so can increase toxicity.  Ask your doctor if you are not sure if you should take Tylenol or other acetaminophen-containing drugs.

Toxicity

Acetaminophen overdoses are not necessarily dangerous; we have good treatment in case of overdose .  As long as the treatment is given within 8-10 hours of an overdose, the chance of liver failure is low.  But if treatment is not sought in time, the destruction of the liver cells is irreversible. That is what happened to the two kids I saw.

Taking a little over the recommended dose won’t hurt you.  It takes more than seven times the recommended dose to cause liver damage.  But taking more doesn’t make it more effective either.  Stick with what is recommended.  I will put a dosage chart at the end of the show notes. 

Acetaminophen is Safe

But hear me on this point: if taken in its recommended dosage, acetaminophen is extremely safe.  It has been used for years by millions of people without problems.  It is good at reducing fevers and relieving pain without risk of serious side effects.  It is still the safest medication for these problems. 

But no drug is totally safe.  Aspirin, decongestants, and even antacids can cause problems if taken in large amounts.  Never take medication you don’t need and certainly never take medication outside of the recommended dosage range unless under the close supervision of your doctor.

Quick and Dirty Tips Regarding Use

So here are my tips regarding acetaminophen:

  1. It is safe to use for fever and pain.  Make sure you read the dosage guides carefully, and consult your doctor if you are unsure. 
  2. Using it outside of the recommended dose doesn’t make it work better can cause serious harm.
  3. Check the labels of any other prescription or over-the counter medications you are taking.  Not doing this could make you accidentally take too much acetaminophen.  Always read labels.
  4. Don’t take acetaminophen if you have liver disease or regularly drink more than two drinks per day.
  5. If you or a loved one has possibly taken too much, seek immediate attention.  Time is of the essence.  Go to the emergency room immediately.

That’s it for today’s episode.  Please remember that though medications can reduce suffering and treat problems, all medications should only be taken as directed and only if you really need them.

References:

FDA Statement: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm168830.htm

List of drugs containing acetaminophen (not necessarily complete):

http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm239874.htm

Good article on the subject:

http://www.medicinenet.com/tylenol_liver_damage/article.htm

Dosage chart for children:

http://www.tylenol.com/page.jhtml?id=tylenol/children/subchild.inc

 [H1]What if you aren’t a regular drinker but know that you are going to have a crazy night, a bachelor party, for example. Should you skip the Tylenol for your knee before heading out that night? Or will it only matter if you are a daily drinker?