The eyes have it...

... an ulcer that is.

The doctor I saw at the Emergency Ward of the Mass Eye and Ear Infirmary on Sunday afternoon says that the ulcer formed over a short period of time, maybe less than three days.

The mild pain and redness Saturday plagued me all during the 7p and 9p at Improv Asylum.
As the irritation persisted into the all night Mission reunion party at Shannon's house I poured Visine on it and ignored it*. In the morning, when the redness still stared back at me in the mirror, I wondered with clinical detachment if I could have a bacterial infection.

When I stepped into the sunlight and was reduced immediately to tears by stabbing pain in the back of my eye - I had no idea what to think.

The ulcer is small, but at the front of my eye. The stabbing pain was related to my iris having small spasms. Secondary to the ulcer I have an inflammation of the iris. To treat the spasms and pain the ER doc used scopolamine, and as a result my eye is no longer sea sick or addicted to heroin.** Also, my pupil is dilated. Light no longer causes agonizing pain in my eye but I've developed an aversion to light a vampire would envy.
Driving the other day at sunset was like driving in a blizzard while a small child played peek a boo with my eyelids.

I've taken to wearing my sunglasses at work under the fluorescent lights. I think it makes me a cooler nurse anyway. Like maybe I'm just as likely to drop some beats as I am likely to irrigate your ulcer. Maybe.

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* Don't do this.
** Pharmacology jokes!

One Step Forward, Two Steps back for low income Mental Health

A short time ago I wrote about MGH's decision to put a substantial amount of funding towards a collaboration between the Department of Mental Health and Boston Healthcare for the Homeless.

This article today in the Globe brought some disheartening news: because of the state's budget cuts the Goldfarb is shutting down. Surely some of the clients from the Goldfarb will be able to get mental health services from BHCHP, but not all of them. This is terrible news for those clients, but also for society in general. Crime rates WILL go up, and public morale will continue to fail.

Gum ,Your Bowels and Society

I once had a patient with severe constipation. Passing flatus, normoactive bowel sounds. But just couldn't go. One of the M.D's at that particular facility told me that he had recently read a study that linked gum chewing to bowel motility, and he even gave me a copy. Apparently it's not exactly novel research because several journals, especially surgical, onco, and GU focused journals have published similar findings.

Because of that I still sometimes write, "encourage gum chewing as appropriate to stimulate bowel motility" in the A/P section of applicable SOAP notes, especially for new post- op patients.

Then I sit and wonder why anyone lets me have a grown-up job.

In all seriousness though, it has been really helpful to several of my patients, and it is evidence based practice, so it's a legitimate plan. I mean, especially in conjunction with something like, "push fluids p.o and encourage prn laxatives as needed." But I just really, really love non pharmacological interventions that have measurable physiological responses. Hot packs and ice, ambulation, pursed lip breathing, weight bearing activity, elevation, relaxation techniques, massage, acupuncture, incentive spirometer use ... I love it all. Medications are very important. And nothing can take the place of getting the proper dose at the correct times (via the correct route!) But when you can add behaviors or actions to create a definable and qualitative increase in quality of health, I think it's even better.

So much can be done just by altering one's lifestyle. Changing diet. Changing exercise habits. In mild cases diabetes can be almost completely managed that way. So can hypertension.

So much can be prevented with life style modifications. But as a society not only are we all about pharmaceuticals but we're also not so much into primary intervention. We'd rather do the damage now and pay for it later.
The exception seem to be middle class 20 somethings who are into being non smokers, doing yoga, shopping at Trader Joe's and going to the gym. (So... Cambridge, MA.) But for the majority of Americans either lack of education or lack of resources or just plain laziness stand in the way of life styles that could prevent major problems down the road. Meanwhile our current health care system is mainly controlled by the Pharm Industry which means that no one at the top has any major incentive to change that.

And so I will continue to include things in my care plans like ginger ale for nausea, elevation for edema, and ambulating ad lib to prevent pneumonia post op. And finding the research to back it up. At least now you know that if you're having trouble with your bowel movements you can go grab a stick of gum. It tastes better than cod liver oil and is cheaper anyway.