Why I Avoid (Most) Hospitals At All Cost

December 21st, 2018

By Natan Schleider, M.D.

A few years ago, I met Rick B (name changed for privacy) at the Lenox Hill Hospital Emergency Room in New York City at around 3-4 am. Rick had severe arm pain and tenderness and I was concerned about necrotizing fasciitis, a deadly bacterial infection that can simply put eat through your skin and cause blood poisoning (septicemia). I had prescribed Rick Ketorolac (which is like super strength Advil–it is not addictive) but the hospital’s pharmacy was not delivering it and Rick was writhing and crying in pain. So I gave Rick his ketorolac, documented all this in the chart and told ER staff, and was pleased to see Rick feeling better.

Later that day, the chairman of the hospital, Jill Kalman, MD, called me. She was furious and short with me on the phone, stating I had put her hospital at risk by giving the patient a medicine that had not come from the hospital pharmacy. I apologized and Dr. Kalman’s response: have security follow me around all day (including into my patient’s rooms) to ensure I did not give patients any more medicines. Neither I nor the security guard (nor the patient) had experienced anything like this.

When Rick said he wanted to go home after the day’s testing confirmed nothing serious, I was happy to discharge him immediately.

The above true story is one of several that remind me why I try to keep patients out of the hospital at all cost. I no longer admit to Lenox Hill Hospital.

You don’t need to be a genius to realize if the hospital does not have the exact medicine you need in a timely manner, is it not reasonable to use your own? The US National Library of Medicine Patient Safety Guide suggests this is reasonable: https://medlineplus.gov/ency/patientinstructions/000501.htm

Prior to Rick’s admission, I admitted a pleasant 90 year old woman, BD, who had never been in the hospital before (except for childbirth) with pneumonia. BD had barely been in the emergency room for an hour before the hospital staff determined that BD should be immediately put on hospice and put out to pasture. BD’s daughter, her health proxy, greeted me with tears in the emergency room saying she felt quite bullied.

My personal experience tells me most patients over 90 with a serious health condition are likely to be pushed toward hospice or palliative care rather than normal care. I understand prognosis in the elderly is poor and many intensive care units are over filled with nonagenarians. That said, patients have a right to comprehensive medical care and if that means it will take a miracle to cure them, visit the local chapel or synagogue, find a good doctor, and provide your loved one with the best care indicated.

BD spent 3 days in the hospital and ultimately died of pneumonia but the family has no regrets, at least they tried.

Thanks for reading,

Dr. Natan Schleider, M.D.

DO I Really Need all these Adult Vaccines?

By Natan Schleider M.D.

December 19th, 2018

Vintatge Diptheria Vaccine Poster Circa Early to Mid 20th Century

Which routine (IE not for exotic travel) adult vaccines do I really ‘need’?

The Center of Disease Control (cdc.gov) provides up to date information on what vaccines each adult ‘needs’

Note ‘needs’ is in quotations as many of my patients say ‘every time I get the flu shot I get sick and I’ve never had the flu so I don’t want it.’ Hard to argue with this logic.

Other patients ‘pass out’ when they see a needle and the CDC doesn’t have much to add for these people.

My goal is a succinct review of all vaccines you’ll need in adulthood based on current 2018 CDC guidelines.

FYI, while I get all vaccines and have no issues with them, my daughter flipped out and cryed and cryed for her 4 year old vaccination so I haven’t had the heart to get her annual flu booster–bad Dr. Schleider.

So here are the vaccine you need in no particular order:

  1. Influenza recommended annually for everybody (unless you are allergic to it).
  2. Tetanus–Recommended every 10 years (5 years if it is a nasty wound like on a rusty fence). Try to get the tetanus booster that contains pertussis at least once in your adult life.
  3. Measles Mumps Rubella and Chicken Pox–You’ve probably had these in childhood (unless born before 1957). If there is any question as to whether you are immune I like to do blood tests for antibodies to confirm immunity.
  4. Shingrix 2 doses after age 50 2 to 6 monthts apart. No one is really using Zostavax anymore…
  5. Pneumonia Vaccine PCV13 (Prevnar) one dose after age 65 unless you have chronic medical issues like kidney or lung disease in which case have it earlier.
  6. Pneumonia Vaccine PPSV23 (Pneumovax) one dose after age 65 (don’t give at the same time as Prevnar) or 1-2 doses before age 65 if you have chronic medical issues.
  7. Human Papilloma Virus–3 doses through age 26 in females, age 21 in males
  8. Meningitis-There a re afew vaccines but bottom line get these before going to college or if you have any immune system disease
  9. Haemopholis Influenza B–Again for patient with compromised immune systems
  10. Hepatitis A and B–Hep B vaccine has become standard and I recommend Hep A to all travelers.

So that is my bare bones synopsis. We haven’t gotten into the exact timing of the vaccines but that is ok, just so you know what to ask your doctor or pharmacist (they get busy and may forget to remind you).

FYI I am a big advocate of vaccines and have had every one from yellow fever to rabies.

Reach out if you have any questions.

Thanks for reading!

Dr. Natan Schleider M.D.

Weight Loss & Lifestyle Tips to A Lean Healthy Physique: Dr. Natan Schleider Shares His Medical Secrets (Shhh Don’t Tell)

ARE YOU TOO FAT. Vintage weight loss advertisement circa 1900

By Natan Schleider, M.D.

December 12th, 2018

Gone are the days where I could simply skip desert and stay rather lean and toned. Having just turned 43, I literally feel my metabolism slowing and all I need to do is look at carbs and they go straight to my gut by osmosis. 

I weighed about 175 pounds (standing 5’9″) into my late 30s but after a recent physical I weighed in at 220 pounds and have shrunk to 5’8″. At this rate I’d be a walking doughnut with a head so I left my doctors office determined to get lean using every bit of advice I could find in the world of medicine, science, and technology.

Its been two weeks and I am down to 205 pounds. I could say I feel great but I’d be lying. My internal barometer seems to want me obese which I qualify for using a Body Mass Index Calculator. I’m tired as I don’t sleep well when I’m hungry. I’m cranky but fortunately I get a lot of telemarketing calls which allow me to toy with people trying to sign me up for ‘limited time offers’ on credit cards, business loans, and Nigerian Gold Mines.

I presume my mood and body will get used to my goal weight which is 180 to 190 pounds if I can get there. 

So here is what has been working to get the weight off…

  1. I go to the gym at least 5 days a week and workout with a trainer. This is my life one big luxury but I am so lazy if I didn’t pay the trainer I would barely work out. The trainer doesn’t let me skimp on those last few squats that leave me dizzy and gets a good laugh when I fall on my face doing box jumps. Bottom line: if you can afford a trainer or have a motivated work out partner that really helps. That said, weight loss is about 80 percent diet so if you cannot afford a trainer and hate the gym most of success lies in meticulous eating.
  2. I started using a My Fitness Pal app which is a real pain because it takes about 5 minutes to enter calories for every meal depending on the number of ingredients. The simpler the meal the faster I can enter and count calories. I’m aiming for 1500 calories daily, a few hundred more if the workout has been strenuous. Some of the things I snacked on like a slice of American Cheese or Prosuciutto have way more calories than I thought so the app has been educational. Even cucumbers have calories and if you are going to lose weight, you need to be rather meticulous in your calculations
  3. I’ve stopped eating out or ordering take out as I cannot count these calories–plus I like to cook so not a biggie for me.
  4. I have prepared healthy meals ready to be cooked or simply heated. I have a great healthy tomato bisque recipe–if anyone is interested let me know.
  5. I have my ‘skinny jeans’ front and center in my closet and try to put them on every few days. They obviously don’t fit (yet) and this negative reinforcement pisses me off, re-motivating me to stick to the diet exercise plan.
  6. Studies show drinking diet beverages can actually cause weight gain and other issues but when I have a sweet craving, I’ll go for a Diet Cherry Coke which is better than Cherry Garcia.
  7. I bough a food scale for about 10 dollars and while I think anyone weighing their tomato wedges is nuts, it is the only way for me to know exactly how many calories I am eating (because the common advice ‘just portion control’ means instead of eating an entire pizza pie, I eat half for dinner and half for dessert).

Some of the above I am sure you’ve read while other may seem somewhere between fanatical and disciplined but if I am serious about weight loss, this is a discipline which takes time and I just hope I can stick with it to the point it becomes routine.

Anyway, thanks for reading!

Natan Schleider, M.D.

Humorism: Why Modern Medicine is Still an Infant or Maybe a Young Toddler

December 11th, 2018

By Natan Schleider, M.D.

‘The Four Humors’ by Granger Drawing Circa 1574

So its the 21st century, you had a physical, and the doctor collected body fluids like blood and urine for ‘sophisticated’ testing. Ah the marvels of modern medicine.

But wait, doctors have been doing this for thousands of years. I would have been one impressed Gladiator in Ancient Rome if my doctor tasted my urine and explained I was feeling weak and urinating a lot because I had too much sugar in my blood. And doctors did just that. No glucose strips or little battery powered devices. Diabetes mellitus was diagnosed with a simple taste test, not blood test. 

Perhaps that doctor sends me to a specialist in Gladiators (who had the status and value of today’s NBA and NFL stars when Rome ruled the world) who likely would do a blood test. Sounds perfectly reasonable. Who wouldn’t want to know if their four humors (black bile, yellow bile, phlegm, and blood) were out of whack.

Today, we honor those four humors and their inventor, a physician known as Hippocrates (460-370 BC):

  1. Doctors take the Hippocratic Oath
  2. We take humors like phlegm and blood of out peoples bodies to test (IE for infection or anemia) and treat them (IE for Polycythemia)
  3. Doctors keep their patients humors in balance by reducing phlegm if they have too much of it so they can breathe

Around the 1500s doctors realized that there may be more to medicine than the four humors but that didn’t stop doctors from bleeding patients therapeutically for virtually any ailments into the early 1900s. Did you know George Washington died of being bled by his doctors for a throat infection. Seriously!

The greatest advances in medicine in the last few centuries include soap (probably saved more lives than all the antibiotics ever created), antiseptic surgical technique, and Viagra (not necessarily written in order of importance).

Sure we have fancy breathing machines, pictures that let us see inside our bodies, and robotic surgery. 

I’m no surgeon but I have to wonder about the bedside manner of robots, I mean, after fixing my heart valve will they reassuringly rest their arm on my shoulder and take a sip of my urine to confirm my diabetes is under control?

Thanks for reading!

Natan Schleider M.D.

Ten Signs You Are Seeing the Wrong Doctor

December 8th, 2018

By Natan Schleider M.D.

If dustballs in the corner of the doctor’s exam room and bullet proof glass separating your from the receptionist aren’t good enough, here are ten signs that you probably are not seeing the best doctor:

  1. An old expression states if the ink on the diploma is to wet or too dry, seek treatment elsewhere. If the diploma is a pile of dust behind a dingy glass frame, run.
  2. The doctor’s lab coat is dirty. This simple observation reflects the doctor’s hygiene and their respect for medicine. Dirty lab coat, dirty doctor.
  3. Magazines in the waiting room are over 10 year old. This shows the office is not up on the times, that is, if they can’t even update their magazines, what kind of archaic medicine is being practiced.
  4. The doctor spends less than a minute with you and can never remember your name. While I grant many doctors are overworked, they can spare a few minutes and knowing their patient’s names.
  5. The doctor is a social media star who does nothing but tweet, post, take selfies, and promote his brand. While I’m sure these doctors are attractive and interesting, they probably are not practicing as much medicine as the good old fashioned doctor–oh, excuse me for a second, someone just liked my latest post on instagram, just joking.
  6. The appointment is spent talking about the doctor and not about the patient (for example, ‘So you just had a little heart attack, big deal, I get my coronaries rota-rootered every year and since my 8th heart attack and some Lipitor, I eat at the buffet daily).
  7. The doctor cannot make a decision and refers you to a specialist for every problem (IE that splinter in your finger is tiny but just to be safe, let’s have a dermatologist look at it to make sure nothing is being missed).
  8. The doctor’s office frequently cancels your appointment or is late for your appointment.
  9. You arrive on time for your appointment and realize yo have read Was and Peace before being called in to see the doctor.
  10. You are asked to disrobe in the exam room for a talk therapy visit.

I’ve seen variants of all of the above so keep the above in mind before choosing your next doctor.

Natan Schleider MD

Which ADHD Medicine is Right for Me?

by Natan Schleider M.D.

December 7th, 2018

So you think you have attention deficit hyperactiviy disorder (ADHD formerly ADD) and you are considering medicine options. If you are like most patients I see, you’ve already queried friends, family, and the internet so you can tell the doctor what you think is best. I have no issues with educated patients so I’ve put together a list of medicines I use and why.

Note the family of stimulants (IE methylphenidate, Adderall, Vyvanse, and others) are the first recommended treatment in general for patients but that varies by patient and whether they have other medical or mental health issues.

Stimulants can be habit forming so considering a non-controlled medicine (bupropion aka Wellbutrin, Strattera) for ADHD may be a nice option as they are not habit forming although tend to be milder and less strong.

While discussing stimulants, let me add that I am often asked ‘Can’t I just drink a lot of caffeine for my ADHD?’ Caffeine is a unique molecule and while it keeps most people awake and is activating, it does NOT help ADHD symptoms.

The first question to ask when it comes to stimulants are whether your want a short acting medicine that can be used a few times a day or a long acting medicine taken once a day. This is patient preference as some like flexible dose options with a short acting medicine while others just like to take one pill a day.

So here are your stimulantmedicine options for ADHD:

  1. methylphenidate (best known as Ritalin) which is the oldest and comes as short acting (last 2-4 hours) and long acting (last 6-12 hours for Concerta or Focalin or Vyvanse–I find they last closer to 6 hours in most patients). Note Daytrana is a patch that lasts up to 10 hours
  2. Dextroamphetamine/amphetaime (Adderall) which comes as short acting or long acting (Adderall XR) and super long acting (Mydayis) at up to 12 hours.
  3. Dexedrine and Dexedrine Spansules are popular amongst a handful of my patients althugh they re hard to find at pharmacies.

 
And here are your non-stimulant medicine options for ADHD:

  1. Atomoxetine (Strattera) which takes about 3 days to kick in and dose can be adjusted from 40 mg to 80 mg (the standard dose) in 3 days.
  2. bupropion (Wellbutrin) is a very activating antidepressant approved for ADHD, tobacco cessation, and depression.

My patients tend to prefer Vyvanse which is the least speedy of the stimulants but every patient breaks the medicines down differently so it may take some trial and error to find the right choice.

When reviewing medicine options with patients I go over the above in detail. While talk therapy helps for most other mental health illneses, it is less effective for ADHD (but no harm in trying it).

If you have any questions or comments please reach out to me on Twiter or Instagram or facebook.

Thanks for reading,

Natan Schleider, M.D.

Herbal Supplements: Helpful, Harmful, or Harmless when using Prescribed Medicines?

Herbal Supplements: Helpful, Harmful, or Harmless when using Prescribed Medicines?

By Natan Schleider M.D.

December 6th, 2018

One of the first things a good doctor does when discussing medical management of an illness is figuring out what treatments the patient is interested in.  Chances are they have already tried cranberry for their urinary tract infections, St.John’s Wort for mood, and a host of other over the counter herbs or supplements which their mother, butcher, or favorite celebrity has recommended.

When these patients come to see me, the melatonin is not really working for sleep and the horny goat weed has not helped libido. These patients may consider trialing a standard medicine when indicated as they feel so bad. Concurrently, they have a strong aversion to taking chemicals bundled into pills that the evil pharmaceutical companies are marketing. After all, if it is natural, it must be better?

When I prescribe a medicine, I need to make sure it will not interact with the herbs that millions of American take so I am writing this blog to weed out (pun intended) the supplements that you can take with other drugs and those that should be avoided or used carefully.

HERBAL DIETARY SUPPLEMENTS WITH LOW RISK OF DRUG INTERACTIONS:  Black cohosh, Cranberry, Gingko, Ginseng (American), Milk thistle, Saw Palmetto, Valerian

HERBAL DIETARY SUPPLEMENTS WITH HIGH RISK OF DRUG INTERACTIONS: Goldenseal, Green Tea Extract, St. John’s Wort

I have not discussed vitamins much and this may lead to a further blog. For example, iron supplements (along with calcium, antacids, and cholesterol drugs) impair absorption of thyroid supplements so take your thyroid medicine 1-2 hours before or after you’ve taken your other medicines and supplements.

I’ve scratched the surface of a major issue but most importantly, tell you doctor and pharmacist what supplements you take so they can tell you how they may or may not interact with your mediation.

Thanks for reading!

Natan Schleider, M.D.

SOURCE: AMERICAN FAMILY PHYSICIAN V.96 No.2 July 15th, 2017