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Ask the Doctor: Frostbite & Hypothermia

My son fell through the ice while ice fishing. What should I do?

Was your son completely immersed?

No. Just his feet—he was in the shallow area.

I did this myself. Falling through the ice puts the body at risk of losing heat faster than the body can burn its fuel to replace the heat loss, which can cause COLD INJURIES ranging from hypothermia to frostbite.

A person’s normal body temperature is 98.6 degrees Fahrenheit. Hypothermia is the term used when our body temperature is lower than 98.6 F. Icy water immersion can rapidly cause hypothermia and frequently the victim becomes disoriented. Other symptoms of hypothermia include clumsy slow movements, longer reaction time, and impaired judgment. Sometimes the mind is so blurred that hallucinations occur.

Treatment of hypothermia depends on the stage in which the victim presents him/herself. In early (less severe) stages, one would usually help the victim out of the cold, replace his/her cold, wet clothing with warm, dry clothing, give him/her warm/hot beverages, or bundle him/her up in a sleeping bag with a companion. In later (more severe) stages of hypothermia, the victim may be found unconscious. If this is the case, wrap him/her in a warm, dry blanket, move him/her to a warm place, and call 9-1-1 immediately. When taken to the emergency room, the victim will be monitored for heart rhythm irregularities.

Your son sounds like he may have a case of FROSTBITE. This refers to a cold injury where one or more parts of the body are damaged by the cold.

As with hypothermia, the person should be removed from the cold and covered with a warm blanket. A frostbitten hand or foot should be warmed slowly in warm—NOT HOT—water. If water is not available, you can tuck your hands under your arms if hands are involved and cover your nose and ears with dry hands if they are involved. DO NOT rub or massage the frostbitten area or disturb blisters. Warm beverages may help. Keep the area clean to prevent infection and go to the emergency room as soon as possible.

If you have to walk out of the area where the frostbite occurred, you might allow the feet to remain frozen, since thawed frostbitten feet are more vulnerable to damage than are frozen feet. In other words, do not thaw frostbitten tissue if there is a chance that it might refreeze before you receive medical attention.

Areas that are most vulnerable to frostbite are the exposed body parts: the nose and ears, the hands and feet. Prevention from cold injuries is the best place to start. Stay dry, bundle up, and wear layers of light, loose-fitting clothes. Wear windproof garments, warm socks and mittens instead of fingered gloves. And be careful not to fall through the ice!

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

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Ask the Doctor: Acute Bronchitis

by John Zettelmaier

My doctor said I have acute bronchitis. I thought I had a bad cold. What is the difference?

Acute bronchitis may be the result of an earlier cold. Both colds and acute bronchitis are caused mainly by viruses, such as rhinovirus, RSV (respiratory syncytial virus), adenovirus, influenza, and parainfluenza virus. Other causes of acute bronchitis include bacteria, pollutants, and allergic reactions.

The big difference between colds and acute bronchitis is their location. The usual cold exists in the head alone, making it an upper respiratory infection. Acute bronchitis is a lower respiratory tract infection, and, in days gone by, it was commonly called a chest cold. The bronchial tree is a series of branching airway tubes that connect the lungs to your nose and mouth. So, a head cold can in fact lead to a chest cold (acute bronchitis).

COUGH. The key word in differentiating colds from acute bronchitis is COUGH. Other symptoms of acute bronchitis include mucus production, chest congestion, shortness of breath, fever, chills, sore throat, body aches, wheezing, and hoarseness. Mucus production or phlegm may be clear, yellow, or green. If your mucus has blood in it, schedule an appointment to see your doctor.

Self-treatment options include:
1. humidifiers and cold-water vaporizers
2. cough suppressants
3. antipyretic analgesics that treat fever and pain
4. plenty of rest
5. lots of non-caffeinated, non-alcoholic fluids
6. stopping smoking (legal and illegal smoking products!)

Most cases of acute bronchitis go away in two to three weeks. The condition is largely self-limited, but you should be sure to see your doctor if, after two weeks, you are still coughing, wheezing, running a temperature, or if you still feel sick and weak. He/she will determine if pneumonia or gastroesophageal reflux or other conditions are present. Sometimes a bacterial co-infection may be present, requiring an antibiotic prescription. Persistent wheezing may need asthmatic medications.

Always remember to READ THE LABEL on any over-the-counter (OTC) medications, as many OTCs are NOT for small children or people with certain medical conditions. Also remember that the OTCs are for symptom relief and do not shorten the length of time the illness persists. In other words, the two- or three-week bronchitis usually lasts two or three weeks. I know it is exasperating, but it is the life cycle of viruses that is to blame, not me or your doctor.

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

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Ask the Doctor: Influenza

by John Zettelmaier, MD

Several students in my dorm have the flu. What should I do?

Living in close quarters like a dorm room increases the chances that you may get the flu. Your chances should decrease if you received the flu vaccine (flu shot). Wash your hands often and buy some over-the-counter medications like Tylenol®, Advil®, etc. If you do get the flu, the Tylenol or Advil or other analgesics will help with the aches, pains, and fever.

Ask the Doctor: Sinusitis

by John Zettelmaier, MD

My sinuses are killing me. What can I do? And what are sinuses for anyway?

There are four pairs of sinuses: frontal (forehead), ethmoid (the area between the eyes), sphenoid (behind the nose, deep in the head), and maxillary (cheekbone area). The sinus and nose mucous lining produces one to two liters of fluid a day. The purpose of this mucous blanket is to defend the body against infection. It traps bacteria and particulate matter that we breathe in, and then sends them down our throat and into our stomach where the stomach acid destroys the invaders. In addition, the sinuses humidify and warm the air we breathe in. The sinuses drain into the nose and any blockage of these small passages predisposes us to the symptoms of sinusitis.

Sinusitis is conveniently divided into two categories: acute and chronic. Acute sinusitis lasts less than one month; chronic or recurrent sinusitis longer than one month. The acute type is generally caused by viral infections, bacterial infections, or allergies. Other causes do exist but are much less common. The viral variety can improve with a trial of self-treatment. The bacteria-caused sinusitis requires antibiotics, so see your doctor. The allergic type also requires a physician’s evaluation.

Symptoms and signs of sinusitis include pain in the eyes, ears, or nose area; fever; headache; fatigue; runny or stuffy nose; post-nasal discharge; decreased ability to smell or taste; cough; dental pain in the upper teeth; halitosis; and tenderness in the sinus areas.

If you are not running a high or prolonged temperature and don’t have severe pain, over-the-counter (OTC) drugs such as acetaminophen or ibuprophen can provide symptomatic treatment of pain and low-level fever. For the cough, an OTC dextromethorphan may provide some relief, and decongestants can help with the stuffy and runny nose. Thick secretions can yield to guaifenesin or nasal irrigation with normal saline solutions, but if you use nose drops, don’t exceed three days. If you go longer, your nose membranes can become “addicted” to the nasal decongestants and won’t work normally without them, yielding a dependence on nose drops to open the nasal passages.

For the fatigue, get plenty of extra rest. And you may find that humidification helps the dry or burning nose sensation.

If you are having severe or persisting symptoms, it’s time to see your doctor. The doctor may prescribe antibiotics or order X-rays or other special procedures.

Good luck!

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

Ask the Doctor: The Holiday Cold

by John Zettelmaier, MD

Every winter, from Thanksgiving through New Year’s Day, I get a “Holiday” cold. We travel a lot at this time and I want my doctor to give me antibiotics, in case we need them on our trips. He says, “No.” Why?

Common cold symptoms include a runny nose, sore throat, sneezing, coughing, and sinus headaches. Sinus headaches usually are in the area above the eyes, below the eyes, or in the cheek bone space. The symptoms may last for days or up to two weeks.

The reason your doctor doesn’t give you antibiotics to prevent or “cure” your cold is that that antibiotics can neither cure nor prevent. Most colds are caused by the rhinovirus. However, over 200 other viruses can cause colds. Antibiotics only work against bacterial infections and NOT viruses.

Taking antibiotics for viruses can be harmful. In fact, indiscriminate use of antibiotics can lead to antibiotic resistance. Resistance works as follows—at any given time there is a bacterial pool that reaches a high enough population to cause disease. Antibiotics kill most but not all of the bacteria in the pool. Those that remain may not have been dividing (duplicating themselves), and the antibiotic did not get incorporated into the cell walls of the bacteria (killing them). But, since the pool population has decreased, your symptoms are gone. These last few bacteria with enough antibiotic exposure develop changes and become resistant, that is, never to be killed by that antibiotic again. This antibiotic resistance develops because only the sensitive bacteria are killed and the resistant bacteria are left to grow and multiply. Decreasing the inappropriate use of antibiotics is the best way to control resistance. Antibiotic resistance is considered one of the world’s most pressing public health problems. The problem is that the infections that were easily treatable with antibiotics now are not. When the antibiotic doesn’t work, the illness lasts longer and requires stronger and stronger and sometimes more toxic replacement antibiotics. Some of these resistant infections even lead to death.

Then, how should I treat my cold?

Your initial treatment usually consists of rest and over-the-counter (OTC) medications for symptom relief. We are NOT talking about “chest colds,” which is the common terminology for bronchitis/pneumonia, which I’ll discuss in a later post. Since OTCs are for symptom relief, use the OTC that fits the symptom.

1. FOR PAIN/FEVER: acetaminophen, ibuprofen, or naproxen
2. FOR SORE THROAT: ice chips, sore throat spray, or lozenges
3. FOR EARACHE: pain medications (listed above) and a warm moist cloth over the ear that hurts
4. FOR RUNNY NOSE: saline nasal spray or decongestants
5. FOR SINUS PRESSURE: warm compresses, decongestant, pain OTCs, or cool mist vaporizer/humidifier

But remember, many OTCs are NOT recommended for children younger than a certain age, so be sure to read the label on the package. IT IS BEST TO CONSULT YOUR DOCTOR BEFORE MEDICATING SMALL CHILDREN.

When your symptoms include a temperature of higher than 100.4 F, last more than 10 days, or are not relieved by the OTC medications, it is time to visit the doctor and find out if, in fact, you have a common cold or something more serious.

Since you are visiting others during the holiday season, remember good hand hygiene. In other words, WASH YOUR HANDS A LOT! Have a safe and healthy trip.

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

Ask the Doctor: Concussions

by John Zettelmaier, MD

My child was “knocked silly” in football practice today. He wasn’t knocked out. Should I be worried about a concussion?

Yes. In most cases, a person with a concussion never loses consciousness. Generally, a concussion is an injury to the brain presenting as a temporary loss of normal brain function. Being “knocked silly” and not unconscious is a concussion by definition. This means that your child’s brain function was disturbed. The child doesn’t have to “pass out” in order to have received a concussion. Brain function disturbance, CONCUSSION, is called by many names. Athletes frequently refer to being “dinged” or having had their “bell rung.”

Concussion symptoms include any of the following after a blow to the head:

- memory loss (amnesia—the best predictor of severity)
- prolonged headache
- visual disturbance (example, blurred vision)
- dizziness
- impaired balance
- confusion (foggy thinking or appears dazed or stunned)
- ringing in the ears
- difficulty concentrating
- sensitivity to light
- loss of smell
- loss of taste
- having trouble following a conversation
- trouble studying or forgetting instructions
- grogginess
- shows mood, personality, or behavior changes
- can’t recall events prior to the injury
- can’t recall events after the head trauma

The brain is a soft organ that is protected by the hard boney skull. The skull protects the brain from trauma just as boney ribs protect the delicate lungs. The impact of a violent force to the head bounces the soft brain around and it hits the inside of the hard skull. The blow can make microscopic brain cell changes that are so tiny even a head CT scan (computed tomography scan) or an MRI (magnetic resonance imaging) can’t find the tiny brain cell changes. The CT scan and MRI are usually normal in concussions, because concussion is a functional rather than structural injury. But the small brain cell changes nonetheless may impact the thinking (cognitive) functions of the brain. Frequently after a concussion, the person may not even remember the causative event or the immediately following events. The doctor examines brain function by history questions (who is the President?), by thinking questions (count backward from 100 by 7s), and by examination of the cranial nerves (follow my finger, checking the pupils, etc.).

Robert Cantu, MD, devised a set of guidelines that was adopted by the American College of Sports Medicine. Roughly, they are as follows:

Grade I Concussion: no loss of consciousness; athlete may return to play if no symptoms are present in one week.

Grade II Concussion: brief loss of consciousness; athlete may return to play in one week if athlete has no symptoms.

Grade III Concussion: slightly longer loss of consciousness or significant symptoms. Athlete is sidelined for one month and then, if no symptoms for a week after the one-month vacation, he/she may play.

There are several scales or tests that physicians or sideline assessors use, including the SAC (Standardized Assessment of Concussions), the SCAT (Sport Concussion Assessment Tool), and the Glasgow Coma Scale, to name a few. They measure and rank thinking and motor functions of the brain, such as time, date, place, and motor responses to verbal stimuli or painful stimuli.

Treatment for concussion is rest (the brain needs time to heal) and acetaminophen (Tylenol®).

Athletes should always wear helmets or appropriate headgear when participating in football, batting, hockey, cycling, skiing, horseback riding, skateboarding, wrestling, or any other activity that presents opportunities for head injury. There are about 300,000 concussions each year from sports-related activity.

So, if your child’s cognitive (thinking) process is ok and he/she doesn’t have any of the symptoms listed above, it is OK continuing the sport but, if you have any doubts, have the child checked over by a doctor.

To learn more about preventing sports-related injuries, read The Awakening of a Surgeon by David H. Janda, MD.

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

Ask the Doctor: Head Lice

by John Zettelmaier, MD

How did my child get head lice?!?!

You are NOT a bad parent. This is NOT a hygiene problem. This is NOT from unclean home conditions. Head lice infestations are common especially when children go back to school or day care.

Children get head lice from person-to-person contact with someone who has head lice. It doesn’t have to be head-to-head contact. Sometimes just sharing clothing such as hats, scarves, coats, and sweaters will spread the little buggers. Even sharing personal items such as combs, brushes, or towels that belong to a child with head lice may lead to an infestation.

Clues to the diagnosis may include:

1. your child comes home with a note from school that says there is a head lice problem in his/her classroom

2. a note from the school nurse indicates that your child has been checked and that lice or nits (eggs) have been found

3. or, your child has been scratching his/her head or complains of scalp itching or a tickling sensation of something moving in the hair.

When looking on the child’s scalp, especially behind the ears or the neckline at the back of the head, you find nits or the tiny lice. Sometimes only the nits of the lice are found. They are tiny white spots on the hair near the scalp by the base of the hair shaft. The nits are pearly white in color. Nit combs (head lice egg combs) can be purchased at the drug store, and sometimes the comb is included with the treatment medications.

If my child has head lice should I be treated, too?

Not necessarily. Only treat family members whose hair has nits or the tiny crawling lice, both of which you can see. Right now you are scratching your own scalp. It is more likely due to the power of suggestion, but check it out anyway.

Should I treat our dog or cat?

No. Human head lice do not live on pets.

What is involved in the treatment?

Treatment usually starts with over-the-counter (OTC) shampoos. Always read the labeled instructions before application. A list of some of the common OTC shampoos is below:

1. Nix®

2. Elimite®

3. Rid®

4. Pronto Plus®

5. A-200®

6. LiceMD®

A second application of the shampoo in 7–10 days is necessary. Read the label and follow the instructions. If you have questions, ask the pharmacist.

For resistant strains of lice, your doctor may prescribe Ovide® (malathion), Kwell® (lindane), or a new medication called Natroba™ (spinosad). Some prescription medications are for children over 4 years old who have not been cured with OTC shampoos.

Combs and barrettes need to be soaked in HOT water for 10 minutes. Wash clothes and pillowcases in HOT water. What about Cookie Monster or Elmo or other stuffed animals with which your child sleeps? Put them in a sealed plastic bag for 2 weeks. If these items have eggs on them, they will hatch, but without a scalp blood source the lice will die. After 2 weeks it is safe to use the stuffed animals again. If some of the clothes are not washable, dry cleaning works.

Now stop scratching your head!

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

Ask the Doctor: Ragweed

by John Zettelmaier, MD

My child has been irritable, sneezing, and has had a runny nose since school started. The teacher reports that he/she is fidgety and won’t sit still. Should I check with my doctor?

Check with your doctor by all means. But, it sounds like your child has a late summer/early fall ragweed allergy.

Ragweed is a prime culprit in causing the above symptoms, and it occurs at its height in September, the time children go back to school. The air-borne pollen starts in August and increases in September. Pollen allergies are one of the most common types of allergies. The weed pollen count as announced by your local TV or radio station is usually the highest between 5AM and 10AM. It is the highest on hot, dry and windy days.

Your child’s symptoms may have worsened waiting for the school bus. If your home and car are air-conditioned the symptoms probably improved. You may have overlooked the symptoms in these air-conditioned environments.

The RAGWEED symptoms include:
1. irritability
2. sneezing
3. runny or stuffy nose
4. coughing
5. itchy eyes
6. itchy nose
7. itchy throat
8. red eyes
9. swollen eyes
10. watery eyes

Try to avoid pollens by staying indoors between 5AM and 10AM. Keep the windows of your home and car closed. Use air-conditioners instead of fans. And don’t hang clothes on an outside clothesline, where the pollen sticks to them; instead, use an automatic dryer.

How will the doctor diagnose my child?

There are medication trials, skin tests, and blood tests. The skin tests are little scratches on the skin (not painful) where little drops of pollens are placed. If the tests are positive, the reaction will be like little red bumps, much like mosquito bites leave. If a large reaction is produced, the site of the skin test may resemble a large red reaction like that of a bee sting. The doctor reads the reactions and will gauge how allergic your child is.

The blood tests are tools for detecting a protein called IgE. This protein is made in your child’s blood if he/she has a hayfever (ragweed) allergy.

What are the available treatments?

The treatment starts at home with trials of over-the-counter (OTC) medications. These are in the antihistamine section of the drugstore. Read the labels, since some of the antihistamines cause considerable drowsiness. Histamine is a substance released in the blood during an allergic reaction and the antihistamines block some of that reaction.

Common OTC antihistamines include:
1. Benadryl®
2. Chlor-Trimeton®
3. Allegra®
4. Zyrtec®
5. Claritin®
6. Clarinex®

Some of the above medications are relatively non-sedating. There are also nose sprays available, such as NasalCrom®, without prescription.

If the OTCs are not successful, your doctor will prescribe additional medications. If these trials do not solve the problem, allergy shots may be indicated.

Allergy shots are called immunotherapy and include getting dilute amounts of the pollen and then building up to more concentrated levels. Shot programs usually run for 3 to 5 years, building up weekly until you get to a monthly maintenance dose. The shots are not significantly painful because they go just under the skin. They are called subcutaneous shots.

So, before you get too concerned about your child’s irritable, nonsocial behavior at school, check with the doctor. The symptoms may be related to his/her allergies. And if so, it would be worth talking to your child’s teachers about what they can expect and when his/her symptoms will stop. Ragweed symptoms disappear after the first killing frost.

Good luck.

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.

Ask the Doctor: Family History

by John Zettelmaier, MD

I’m nervous about seeing a new doctor. What information should I share with him/her?

When talking to your doctor you’re nervous; you’re in the doctor’s office. This is no time to try to remember important information. Some doctors may ask you to complete a form listing complaints and concerns. If this is your doctor’s practice, complete it ahead of time and/or bring in a prepared list.

Write down other concerns or complaints beforehand in the comfort and security of your home where you will not be intimidated by the sights, sounds, and smells of the doctor’s office. The list should start with the most important complaint/concern first. If, for example, you are tired all the time and you also have had a recent series of nosebleeds your list may read (1) tired all the time and (2) nosebleeds. Don’t worry about how you express your concerns. Your doctor can translate or clarify them with you.

To do that, the doctor may reorganize your list as he/she asks you more questions. The doctor may wonder if the nosebleeds are because you have leukemia (a very serious disease) or are related to anemia (a not-so-serious problem). Both can cause fatigue. Sometimes insignificant complaints link together and give clues to the doctor. Sometimes concerns are unrelated; the nosebleeds might be related to sinus problems and the fatigue to sleep disturbances. In either case, be sure to write them down so you don’t forget them in your nervousness and unease at the office.

Your FAMILY HISTORY is also important. Write it down as well.

List the diseases that your ancestors currently have or that caused their deaths. Examples:

1. my dad has diabetes

2. my grandfather died of cancer of the prostate

3. my mother has to take thyroid pills

4. my grandmother has rheumatoid arthritis

These examples of family histories help the doctor look at possible genetic influences regarding your current symptoms. Also include the history of your siblings’ problems since this may point to conditions your physician may wish to investigate.

Some studies suggest that 40–50% of depression may be genetic (inherited tendency or predisposition). Additionally, studies indicate that anxiety aggregates in families and it is possible that this familial link results from genetic factors. Genetic factors are expressed in many diseases or syndromes, including rheumatoid arthritis, diabetes, irritable bowel disease, gout, and obesity.

Keep a list of your personal illnesses, immunizations, medications (dosage, frequency, and reason for taking), and allergies. (This list should be carried with you at all times, in your wallet or purse.) These lists help the doctor get a more thorough look into your current complaints. For instance, if you take a lot of aspirin for various reasons, this may help the doctor sort out your complaint of fatigue. The tiredness may be from anemia that can be caused by aspirin.

Allergies to medicines (such as antibiotics) or dyes (like those containing iodine) are important for your physician to know about when he/she is ordering certain medicines, X-rays, or other procedures.

PERSONAL AND FAMILY HISTORY are clues to the diagnosis. Write them down!

John Zettelmaier, MD is a graduate of the University of Michigan Medical School, a member of the Beta Beta Beta Biological Honor Society, an American Board of Family Practice Diplomate, an American Academy of Family Physicians Life Member and Fellow, and a Life Member of the Michigan Academy of Family Physicians.