Category: Medicine Page 2 of 3

Of course there will be medicine. I am The Grumpy Doc.

Understanding Medical Care Guidelines

On August 7, 2024

An important discussion to have with your physician.

Trivia question: What are medical guidelines? Are they rules we must follow or are they simply suggestions or are they something in between?

As we get older and have more frequent visits to the doctor, we are bound to hear one of them say, “according to the guidelines”. To understand how the guidelines apply to you, it is important to know how and why they are developed. You also need to know if there are ever times when you shouldn’t follow them.

At the end of this article, I’ll tell you about my experience with one specific guideline, and how strictly following it possibly could have led to a bad outcome for me. But first, let’s learn a little more about medical guidelines.

Medical care guidelines, also called clinical guidelines, come in two general classes. There are guidelines for preventative care and guidelines for the management of disease processes.

Guidelines have several goals. They are intended to improve public health by recommending evidence-based preventive and treatment measures to help reduce the incidence and severity of disease and improve overall public wellbeing. They’re designed to optimize resource utilization by preventing unnecessary treatment and screening tests. They are also intended to reduce health care disparities by ensuring that all recommended treatments are widely available and are based on the most up-to-date evidence so that health care across the nation is at a uniformly high level of quality.

Sources of Guidelines

Preventative care guidelines have to do with such things as cancer screening, cardiovascular health, vaccinations and immunizations, and lifestyle improvement such as diet and exercise recommendations. Disease management guidelines are developed to ensure the best possible treatment for diseases such as hypertension, diabetes and pulmonary disease.

Guidelines are developed by physician groups such as the American College of Physicians and the American Academy of Pediatrics. They are also developed by advocacy groups such as the American Cancer Society and the American Diabetes Association. Government organizations such as the Centers for Disease Control and Prevention and the National Institutes of Health also develop and promulgate medical care guidelines.

The United States Preventative Services Task Force (USPSTF) is an independent panel of experts in prevention and evidence-based medicine. They issue recommendations on a wide range of preventive services including screenings, counseling and preventative medications. The USPSTF rates medical care recommendations from Grade A, those with a high certainty of substantial benefits, all the way to Grade D, those services that are not recommended due to having no benefit or having harm that outweighs benefits. Their recommendations can be viewed at www.uspreventiveservicestaskforce.org.

Preventative care guidelines

Preventive care guidelines are designed to help identify and mitigate potential health issues before they become significant problems. They help to ensure adequate screening for significant disease processes. They are also designed to help avoid unnecessary screening which may lead to unnecessary treatment and cost.

Preventative care guidelines include such things as mammogram recommendations, colonoscopy recommendations, blood pressure and cholesterol screening, and prostate cancer screening. Preventative care guidelines also include recommendations for vaccinations both for children and adults. Recommendations on diet and the use of vitamins and supplements are one area where the guidelines seem to change frequently.

Treatment guidelines

Treatment guidelines provide a roadmap for managing specific medical conditions. These recommendations encompass diagnostic procedures, therapeutic interventions, and follow-up care to ensure optimal patient outcomes.

Treatment guidelines include recommendations for such things as initiation of blood pressure management and diabetes management. They provide recommendations for diagnostic modalities and specific medications and dosages.

For example, treatment guidelines include blood pressure levels at which medication should be started, the goal of treatment and specific medication, depending on what other medical conditions the patient may have. Similarly, there are blood glucose management recommendations for diabetics that are tailored to specific patient populations. The use of bronchodilators and pulmonary rehabilitation and oxygen therapy for lung diseases are also the subject of a series of guidelines. Treatment guidelines continually evolve as new medications are developed and our understanding of disease processes improves.

Understanding the variability in guidelines.

While the guidelines developed by the various organizations share a common goal of improving patient care, their methodologies and focus areas can differ, reflecting diverse perspectives and priorities within the medical community. There’s not a single set of guidelines that are fixed across all specialties. While the various guidelines are generally in agreement, some may have slightly different recommendations for such things as the onset and aggressiveness in treating hypertension or diabetes. There may be variations in the guidelines for diagnostic testing such as mammograms or colonoscopies. For example, the USPSTF recommends biennial mammograms for women aged 50 to 74, whereas the American College of Surgeons advises annual mammograms starting at age 45 and transitioning to biennial screening at 55. The discrepancy lies in differing interpretations of the balance between benefits and harms of more frequent screenings.

Some guidelines may also become outdated, not reflecting new medications or new treatment plans. Even where there are variations, all guidelines strive to be evidence based, patient centered, and up to date.

Additionally, guidelines need to be individualized to meet the needs of each patient. The overall guidelines are based on the most effective health care for the population as a whole. Some patients may require specialized screening or treatment. For example, women who have a family history of early onset of breast cancer or of genetic mutations may require screening at an earlier age or more frequent screening. Men with a family history of prostate cancer at a young age or of a particularly aggressive prostate cancer may require earlier screening including biopsies or may need screening beyond the age that general guidelines recommend screening is no longer necessary.

My Experience

Several years ago, I received a diagnosis no one wants to hear. Cancer! Prostate cancer to be specific. Thanks to two skilled urologists, I’ve been cancer free for five years.

But it might not have had a happy ending. Please indulge me and let me tell you my story. I think it will be worth your time.

It starts with the PSA, the prostate specific antigen. This is something every man over 40 should know about and every man over 50 should consider getting checked.

So, what is the PSA? It is a protein that is produced by both cancerous and normal cells of the prostate gland. It can be elevated by prostate cancer but it can also be elevated by prostatitis (an infection of the prostate) or an enlarged prostate (benign prostatic hypertrophy). It is checked through a simple blood test your family doctor can order as part of your annual work up.

What are the recommendations for the PSA? The USPSTF has the following three recommendations: (1) consideration of annual screening for men aged 55 to 69 with no family history of prostate cancer; this should be a shared, informed decision between the patient and his physician; (2) for men who have a significant family history of prostate cancer consideration should be given to screening beginning at age 40; (3) for men over 70 years old they recommend against screening for prostate cancer. Please note the phrase “consideration of screening”. This is not a firm recommendation.

A PSA test can have false positives that may lead to unnecessary biopsies or surgery. Only about 25% of men who have a prostate biopsy are found to have cancer. Although, it is important to recognize that a prostate biopsy does not test the entire gland. It takes samples from several areas of the prostate. It is possible, though unusual, that a cancer could be missed in the biopsy process

Additionally, most prostate cancer is very slow growing. Most men who have prostate cancer later in life will generally die of something else before they would die of prostate cancer. However, a small percentage of men will have a high-grade prostate cancer that can progress rapidly and cause their death.

I’m going to use my personal experience as a way of explaining why it is important to have a discussion with your physician about guidelines. The week before my 70th birthday I went in to get my annual physical. In our clinic we have a “birthday panel”, a set of blood tests that we draw for people annually for their physical exam. I had not planned to have my PSA checked since it was not recommended by either the USPSTF or the American Academy of Family Physicians for 70-year-olds. However, it had slipped my mind that a PSA was part of our “birthday panel”.

My PSA came back slightly elevated. Since it was a very minor elevation, I followed the guidelines and waited six months and repeated it. At that time, it increased only a small amount. The guidelines suggested repeating it again in six months. I have to admit though, I have never been a wait-and-see kind of guy. I scheduled an appointment with a urologist.

The urologist and I discussed the options. He told me that the elevation was slight, and we could wait and repeat it in 6 months or if I wished we could do a biopsy. I decided on a biopsy and then after receiving the biopsy results and having further discussions, I eventually decided on surgery. It was my decision, as it should be, made in consultation with my physician and my family.

The post-operative pathology report said that there was a high-grade carcinoma that apparently had been missed by the biopsy. It had extended beyond the capsule of the prostate. Fortunately for me it had not metastasized and had not spread to the lymph nodes, nor had it extended beyond the fat layer surrounding the prostate. Had I followed the guidelines and waited another year or even six months for a repeat biopsy, it is possible that the outcome may have been different.

What’s the bottom line?

Does my experience mean that the guidelines should be ignored? Far from it, I made an informed decision, in conjunction with my physician, on what was best for me. Additionally, I have followed the guidelines in the management of my hypertension and high cholesterol.

Healthcare guidelines are essential in promoting preventive care and effective treatment and in helping clinicians provide high-quality, evidence-based care. But the guidelines are just that, guidelines they are not “set in stone” rules for healthcare. It’s important for you to discuss your health care with your physician. Be an informed health care consumer. Ask how the guidelines are being used to manage your health care and how they may be affected by your family history or personal history. You and your physician should be involved in joint decision making. Your individual plan will generally follow the guidelines while having some variation based on what is the best care for you. And that’s what the guidelines are all about, making sure we are able to provide the best possible health care for all of our citizens.

Stand Strong: Protect Yourself From Falls

By John Turley

On May 11, 2024

In Commentary, Medicine

Not too long ago I decided to spend my lunch break from the clinic by taking a walk around downtown. It was a beautiful day. It was warm, the sun was shining, and the sky was bright blue. I just started my walk when I thought I heard tires squealing behind me. I looked over my shoulder and as soon as I did, I felt my foot catch on a piece of broken concrete, and I went down hard. Fortunately, I fell right in front of my office and even more fortunately I work for the ambulance authority. Within minutes I was surrounded by paramedics and a nurse practitioner who made sure I was well taken care of. My CELLULAR watch also helped save the day. I’ll talk more about my experience later in this post but now I’d like to talk about falling in general.

Those of us of a certain age have gotten used to having every visit to any type of medical appointment include the question: “Have you fallen recently?” Even though I know the reason for this, it still annoys me. They always assume older folks are going to fall. (I think I’ve told you before, I preferred to use the term older folks or even old geezers for that matter but, I refused to be labeled as elderly.)

It’s been estimated that over 25% of older adults fall each year but probably less than half of those will report the incident to their health care provider. Once you’ve fallen your risk doubles that you will fall again. As we advance in age, falls become the leading cause of both fatal and non-fatal injuries.

Chronic medical conditions such as diabetes and heart disease can increase our risk of falling by affecting our blood pressure and causing dizziness. Some of the medications we take can have the same side effects. Also, older folks are less likely to eat or drink adequately leaving them more susceptible to dehydration and fainting. If these things are happening to you, it’s important to let your doctor know so together you come up with a plan to protect yourself.

Environmental factors also play a critical role in falls. Common hazards include loose rugs, wet floors, uneven surfaces, curbs, icy sidewalks, and dropped objects. As I found out, what would have been a simple stumble with a quick recovery when I was younger became a hard fall.

So why is that? As we age arthritis can cause stiffness in our joints which slows our reaction time. Loss of muscle mass and with it decreased core strength make it harder for us to maintain and regain our balance. Changing eyesight makes it difficult to tell where objects are in relationship to one another. As we get older, we tend to shuffle or drag our feet when we walk making us more susceptible to the uneven surfaces. I know that’s one of my major problems.

There are many resources people can use to reduce their risk of falling. I’m sure you all know about them: strength exercises, flexibility and balance classes, and regular stretching can be very helpful. There are many websites that tell you how to fall-proof your home and workspace. And of course, everyone should get a regular checkup to make sure that they don’t have undiagnosed health problems.

Now, I want to tell you about the one thing that I thought was very important for me in my fall. I’ve always been a gadget guy. A few years ago, I decided to get an Apple Watch. I like the idea of being able to get a weather report, check my e-mail, check my texts, check my calendar, and answer the phone all from my wrist. And, because I am a gadget guy, I got the one with cellular capability. I never really expected to make use of it, I just thought it seemed neat.

As competitive as the smart watch market is, I’m sure they all have similar capabilities. I’m not an expert on any of the others, but I do know about the Apple Watch, and I’d like to tell you about it. The watch comes with a fall alert and SOS system. If you fall like I did, you immediately get a notice on your phone that says it looks like you’ve had a hard fall, to which you can either respond “yes send help”, or “no I’m fine”. If you respond yes, it sends your GPS coordinates to 911. If you respond no, it asks if you’re sure, to which you again respond that you are sure and then that’s the end of it. If you do not respond at all or the watch detects you aren’t moving, it waits a few seconds and then sends your GPS coordinates to 911. I know a lot of people are concerned about technology tracking them. Well, I’m glad it does.

And now back to being a gadget guy. This is where the cellular option paid off for me. The SOS fall protection system only works when your phone and watch are in range of one another. You can only make calls from your watch when they were in range as well. Unless, you have a cellular capable watch which works independently.

I know most people think they won’t go anywhere with their watch without their phone. Well, that’s what I thought. But that day, I inadvertently left my phone on my desk. And when I fell, I couldn’t get up. I told my watch not to send my information to 911 because I was right in front of the ambulance authority. I called into the office and very quickly had all the help I could ever want. But if I had not had a cellular capable watch I would either have had to crawl into the office or lay there on the sidewalk until somebody stopped to help me. Which someone did almost immediately. So, there are Good Samaritans in Charleston.

So, my bottom-line recommendation to you is to get a smart watch, whatever type you prefer, and make sure it has cellular capability. Don’t do anything including housework, yard work, or even taking a walk at lunch that may have any risk of a fall without having your smart watch with you. As I found out, the risk of falling is greater than you think. I wish I were getting compensation for pitching this technology.

The Triumph of Ignorance

By John Turley

On April 30, 2024

In Commentary, Medicine

“There are two ways to be fooled. One is to believe what is not true; the other is to refuse to believe what is true.” – Søren Kierkegaard

Saturday morning, I was reading in the newspaper about the resurgence of measles in West Virginia. I find it appalling that this disease should be returning, given that we have safe and effective vaccinations. What is next, polio, smallpox, or even plague? It is only through the unexpected veto by our governor that the ill-advised bill passed by our legislature to make all vaccinations virtually optional did not become law.

Some people may wonder why vaccinations are important. There are two principal reasons to ensure that a large portion of the population is vaccinated against communicable diseases. The first is that it reduces the individual vulnerability to disease. The person who is vaccinated is protected. But there is also a second, sometimes not well-understood, reason. That is herd immunity.

Communicable diseases require a large susceptible population to spread. When a significant portion of the population has been vaccinated the disease does not have the core of potential victims to allow spreading. This means that the vaccinated are protecting the non-vaccinated. However, it does require a large portion of the population to be vaccinated. The idea is that herd immunity will protect those who are unable to be vaccinated either due to age, allergies, or other medical conditions that would prohibit vaccination. Herd immunity is never going to protect a large proportion of the population who just choose not to be vaccinated. For example, about 90 -95% of the population needs to be vaccinated against measles to provide herd immunity.

So why do people who otherwise can be vaccinated choose not to be?

There are, of course, those who have true religious objections to vaccination. These people have long standing, deeply held convictions. Their opinions derive from study, prayer and reflection based on the tenants of their faith. They did not have a sudden anti-vaccine epiphany after listening to the poorly informed rantings of a demagogic politician.

There are many who mistrust the medical system. There were some cases in the past where unethical studies were conducted on unsuspecting populations. Given the rigorous oversight of medical research now, this no longer happens. Information about research into vaccinations and their safety and efficacy can be found on websites for the Centers for Disease Control and Prevention and the World Health Organization among others. (Website references are provided at the end of this post.)

There are others who object to vaccination on the basis of personal autonomy. They believe their right to refuse vaccination outweighs any consideration of the health concerns of the frail members of our community. This is certainly not reflective of the spirit of charity towards all that I was raised with.

What concerns me most are those who refuse to believe reputable medical authorities, government agencies, and mainline news services. They prefer to get their information from anonymous websites or from conspiracy theory websites that still give credence to such sources as the now-discredited 1999 study linking the MMR vaccine to autism. They completely ignore the fact that 10 of the 11 reported co-authors disavowed any part in the published conclusions. They also ignore the fact that the principal author was found guilty of fraud for personal gain as he was employed by the manufacturer of rival drugs. They also ignore the fact that he lost his medical license over his falsifications in this study. Yet, he is still cited in anti-vaccine literature as an expert source.

Equally disturbing is the fact that vaccine resistance has become a part of political identification. Certain reactionary political groups have, for some unfathomable reason, decided that refusing vaccination is a badge of their political allegiance. They seem to care more about maintaining their political purity than they care about science, public health, or even the welfare of their family and friends. Politicizing public health is dangerous for all of us. I’m not sure how we overcome this. It is easy to find the truth and verify it through fact-based studies, yet people refuse to do it.

I encourage everyone to work hard to ensure that our political leaders do not remove vaccination mandates for school children. For those of us of my age, we already have immunity through vaccination or prior exposure to the disease. It is our grandchildren and their children and their children’s children who will suffer through the return of these deadly diseases.

SOURCES:
World Health Organization: https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_1

CDC: https://www.cdc.gov/vaccines/index.html https://www.cdc.gov/vaccines/hcp/vis/index.html

WV DHHR: https://oeps.wv.gov/immunizations/Pages/default.aspx
Immunise.org: https://www.vaccineinformation.org/

I Couldn’t Sleep At All Last Night -Bobby Lewis, Tossin’ and Turnin’

By John Turley

On October 1, 2023

In Medicine

Sleep Part 2

Several different processes fall into the broad category of sleep disorder. But first, we should understand a few things about what constitutes a sleep disorder.

Not everyone requires the same amount of sleep; children and adolescents require more sleep than adults. Once we reach adulthood, our individual need for sleep usually becomes fairly consistent for the remainder of our lives. However, the amount of sleep needed varies from person to person.
A common misconception is that we require less sleep as we age. It is true that older adults frequently get less sleep but it’s not necessarily because we require less. Admittedly there is some controversy among sleep specialists, but we shouldn’t dismiss the concerns of older people because we don’t think they need as much sleep as they used to.

To diagnosed as a sleep disorder, it must be a relatively long-term process. An occasional night of sleeplessness does not constitute a sleep disorder; there must be some impact on the waking hours. For example, a person who only sleeps 5 to 6 hours a night but never has any daytime sleepiness, fatigue, difficulty concentrating, or completing tasks probably does not have a sleep disorder. Another person who gets 7 to 8 hours of sleep a night but feels drowsy, is unable to concentrate on tasks and drifts off to sleep midafternoon may have a sleep disorder.

A sleep disorder is never diagnosed by the time spent in bed. It is diagnosed based on how a lack of sleep impacts daily life and ability to function at the desired level. It’s very common for people to overestimate the amount of time they are awake at night. A sleep disorder is something that requires careful investigation. It is important to contact your doctor for a definitive diagnosis.

If there is another reason for sleeplessness, then a sleep disorder diagnosis should not be made. Common causes of sleep disturbance are pain and environmental factors such as noise, bright lights, and temperature extremes. Rotating shift work is another common cause.

It is important to determine if the person reporting sleep problems has adequate opportunity to sleep. Family demands or work requirements may often limit the ability to get sufficient sleep. Additionally, some older men make frequent trips to the bathroom during the night, but this doesn’t necessarily constitute a sleep disorder.

To diagnose a sleep disorder, the patient must have had the opportunity for adequate sleep but is still suffering from the symptoms of sleep deprivation. The first step in evaluating a sleep disturbance is to identify and eliminate as many external factors as possible.

Sleep Apnea
Sleep apnea is perhaps the best known sleep disorder. There are two types of sleep apnea, the fairly common obstructive sleep apnea (OSA) and central sleep apnea. Central sleep apnea is extremely rare and well beyond what we’re talking about here.

Most OSA patients complain of daytime sleepiness. A patient’s bed partner may report loud snoring, gasping, or snorting, or the patient seeming to stop breathing while asleep. Not everyone who snores has OSA. While about 80 to 90% of people who have OSA snore, fewer than 50% of snorers have OSA.
If you are concerned that you may have OSA, talk to your doctor. It’s not something that can be diagnosed by you at home. Diagnosis requires a formal assessment.

Sleep apnea is treatable with the infamous CPAP machine. It isn’t generally considered to be curable although some people who have lost a significant amount of weight have been able to wean themselves from the CPAP machine.

Insomnia

Insomnia is one of those catchall medical terms that covers a variety of clinical situations. The broad definition of insomnia is difficulty sleeping. But that includes many causes, both those understood and those not well understood.

During a sleep assessment, it’s important to determine if it is chronic insomnia. That is a pattern of difficulty falling asleep or staying asleep that occurs at least three nights a week and lasts for at least three months. But that’s only the beginning, there are many unrelated factors that can cause chronic insomnia and there are also different types of insomnia that may be unrelated to any other factors.

Onset insomnia is difficulty falling asleep. The patient may be awake for very long periods, but once they fall asleep, they’re usually able to sleep for several hours. Unfortunately, they are usually awakened by the alarm clock before they have experienced adequate restorative sleep.

The other broad category is maintenance insomnia, the difficulty staying asleep. These patients often wake up in the middle of the night and are unable to return to sleep for several hours. Frequently they report falling back asleep just before the alarm goes off.

Some people have mixed insomnia. Sometimes they will have difficulty falling asleep and at others, staying asleep. Occasionally, they will suffer from both types on the same night, making for a very long night indeed.
Both types of insomnia can have similar underlying causes. Some of them fit in the broad category of comorbid insomnia, whether it’s a medical, psychiatric, or other problem. This can include depression, anxiety, or somatic disorders such as restless leg or chronic pain. Medical disorders include pulmonary disease, diabetes, and congestive heart failure. Treatment of the underlying medical condition is the key to dealing with these types of sleep disorders.

In a self-fulfilling cycle, some people suffer from insomnia because they worry about their inability to sleep.

Another type of sleep disturbance frequently included in the category of insomnia is disruption of the circadian rhythm. The circadian rhythm is the body’s internal clock. It is generally a 24-hour cycle that follows the light-dark cycle of the day. Major circadian disruptions include jet lag and intermittent shift work. The use of LED screens such as televisions, computers, and E readers exposes us to a large amount of blue light which may confuse our body’s circadian rhythm into thinking it is a daylight period. The many effects of disrupting the circadian rhythm are beyond the scope of this post, but if your circadian rhythm is interrupted it can affect your sleep, at least in the short term.

In Part 3 we will look at those things that may help you sleep.

A quote to end this post:
“I’ve always envied people who sleep easily. Their brains must be cleaner, the floorboards of the skull well swept, all the little monsters closed up in a steamer trunk at the foot of the bed.” – David Benioff, author, and TV producer

To Sleep, Perchance to Dream -Wm. Shakespeare, Hamlet

By John Turley

On September 2, 2023

In Commentary, Medicine

Sleep – Part I

The other night, about 3:00 AM I was lying in bed wide awake thinking about…. sleep. It’s natural to think about sleep when you’re having trouble doing it. I’ve had intermittent insomnia for my entire adult life. Sometimes I’ll go several days with not much more than two or three hours of sleep a night and then I’ll go several days where I can sleep six, seven or eight hours. I’m not sure what causes insomnia at one time but not another.

I’ve spent a lot of time thinking about sleep. Mostly, I think about why I can’t sleep and what I can do to get to sleep. I’ve read a lot about specific tips and techniques to improve sleep. I’ve tried many of the so-called “sleep hygiene” regimens. I’ve tried herbal preparations and prescription sleep medications. Lately I’ve been using a sleep mask with some positive results. I’m easily awakened, and it has helped with that.

But, with one of those middle of the night revelations, I realized that in all my years of thinking about sleep I’ve never really thought about what sleep is and why we need to do it. So, I’m going to embark on a three-part post about sleep. This is Part 1; it’s a look at what sleep is and why we do it. In Part 2 we’ll look at why we can’t sleep and the various things that cause us to lose sleep. Part 3 will be a survey of the many things available that may or may not help us to get that good night’s sleep.

What Is Sleep?

We will spend anywhere from 25 to 30% of our lives asleep so we really ought to have a better understanding of exactly what it is.
Merriam-Webster defines sleep as: The natural, easily reversible periodic state of many living things that is marked by the absence of wakefulness and by the loss of consciousness of one’s surroundings, is accompanied by a typical body posture (such as lying down with the eyes closed), the occurrence of dreaming, and changes in brain activity and physiological functioning….

As with many dictionary definitions my first response is “What?” So, let’s see if I can come up with something that’s a little more than a physical description of someone laying on the couch asleep.

Our bodies crave sleep just like they crave food. The major difference is your body can’t force you to eat but it can force you to sleep.

The reasons why we sleep and what happens during sleep are not completely understood. People used to believe that sleep was a passive activity when the brain and the body were dormant. But, according to sleep specialist and neurologist Dr. Mark Wu, MD “… it turns out that sleep is a period during which the brain is engaged in a number of activities necessary to life which are closely linked to the quality of life.”

Cycle of Sleep

Everyone’s heard of the sleep cycle so I’m just going to briefly touch on it here. There are two basic types of sleep. The first is non-REM sleep which also has three stages of its own and the second is the rapid eye movement (REM) sleep.

The three stages of non-REM are Stage 1 which is the transition into sleep and is relatively light. It is when brain waves begin to slow down. Stage 2 is the period just before you enter into deeper sleep when your heart rate and breathing slow, your muscles relax, your body temperature starts to drop, and eye movements stop. This is the stage where you spend most of your sleeping time. Stage 3 of non-REM sleep is the period of deep sleep that you need to feel refreshed in the morning. It occurs more during the first half of the night. Your heartbeat and breathing are slowed to their lowest level, and you are most relaxed. Brain waves are at their slowest.

REM sleep first occurs about 90 minutes after falling asleep. Your eyes move rapidly even though your eyelids are closed. Your brain waves are closer to those when you are awake. Breathing becomes faster and your heart rate and blood pressure increase. This is when most of your dreaming occurs. Although, some can occur during non-REM sleep periods. During REM sleep your arm and leg muscles may become temporarily paralyzed which prevents you from acting out your dreams. As you age, you spend less time in REM sleep.

What Happens When We Sleep?

If we’re going to spend this much time sleeping there must be some benefit to it, right? Surely it is not just a way to pass the time until we have something better to do.

There have been a lot of theories over the years about why we sleep. Some of the older ones include the adaptive or evolutionary theory that says animals sleep during periods of vulnerability, such as darkness, so that they won’t attract attention. However, this seems to be counterintuitive. During periods of vulnerability, I would certainly want to be most alert. Another theory is that of energy conservation. During periods of sleep the body has less need for energy and will not require food as often. For most of human history, and continually for the rest of the animal world, food is a scarce item and energy conservation is important to survival.

People have always recognized that somehow sleep helped rejuvenate us. Newer research points to this as probably the main reason why we sleep. Sleep helps clear the brain of waste products that accumulate when we are awake allowing it to function more efficiently.

Sleep also helps us consolidate the day’s memories. It facilitates the conversion of short term to long term memories so that they are more readily accessible. Sleep also improves alertness, concentration, and cognitive performance. This may be why some people recommend a good night’s sleep rather than an all-night cramming session prior to finals.

Sleep helps regulate various hormones that are responsible for appetite control, growth, and metabolism. Poor sleep can exacerbate physical problems such as diabetes, hypertension, and obesity. Sleep is essential to our immune function; prolonged periods of sleep deprivation put us at risk for opportunistic infections. Sleep is also important for our emotional well-being and for helping to prevent anxiety and depression.

I will finish this post with two quotes that I particularly like about why we sleep.

Sleep is an investment in the energy you need to be effective tomorrow.
-Tom Rath, American author and consultant

Sleep is the golden chain that ties health and our bodies together.
-Thomas Dekker, 17th Century English poet and playwright

Persistence of Memory

By John Turley

On August 11, 2023

In Commentary, Medicine

I turned 75 this year and like many people my age I have started to worry about my memory. I’ve always had a good memory. I seldom had to write anything down and I almost never forgot anything. But that’s rapidly becoming a thing of the past. I try to tell myself it’s because I don’t need to remember things now. I have my phone with my calendar and my to-do list and my reminders all right there in my pocket. Things for which I once relied on my memory are now just a simple “buzz” away. As much as I try to tell myself that, I can’t really believe it. I’m afraid things are starting to slip away, and I worry just how far and how fast this will progress. I know from talking to others my age I am not the only one with this concern. But what exactly is memory? How does it work? And what can we do to prevent its decline, or even better to reverse it?

What is memory?
Marriam-Webster Dictionary defines memory as: “…the power or process of reproducing or recalling what has been learned and retained especially through associative mechanisms; the store of things learned and retained from an organism’s activity or experience as evidenced by modification of structure or behavior or by recall and recognition.” I hope that’s more enlightening for you than it is for me. While it may describe memory, it doesn’t really explain it.

I think that I like Salvador Dali’s approach to memory. In his famous painting shown above, The Persistence of Memory, we see the passage of time as it inexorably moves on but leaves persistence in our memory. But as we can see memory is fluid and it is malleable. While memory may persist, it is not unchanged. OK, that may sound like philosophical mumbo jumbo, but I just want to get across the idea that memory is not a concrete thing, and it is as much about perception as anything else.

Types of memory

One of the first things to recognize is that memory is not a single monolithic sense. There are many types of perceptions or abilities that are encompassed in the collective term memory.

The type of memory we use most frequently is working memory. This is where we store things for short-term use. It would include things such as remembering numbers to add in your head. You don’t need it for long term, but if you have problems with your working memory it can take you much longer to get things done such as balancing a check book, following directions or grocery shopping.

Episodic memory is how we recall past events, personal experiences, conversations, feelings, and emotions. If you’re struggling to recall recent events and activities, you may have a problem with your episodic memory. This is the type of memory loss that most people first worry about.

Semantic memory is what you use to recall the definitions of words, the names of objects and to recognize familiar faces. It’s not tied to any specific experience, but these are just things that you just know, such as your key is used to unlock your door or if you want a drink of water, you pour it into a glass. If you find yourself frequently struggling for the right words in a conversation you may be having problems with your semantic memory.

Our prospective memory is the way we remember future things. It’s how we keep track of appointments and obligations. If you find yourself forgetting that you have made plans or where you were supposed to be going you may have problems with your prospective memory. We most commonly experience this when we find we have walked into a room, and we can’t remember why we went there. (Unless it’s the bathroom; I always remember why I’m there.)

Is it dementia?

Of course, this is our greatest worry. I think many of us fear dementia more than we fear stroke, heart attack, or cancer. Memory loss is not always dementia; there is some natural degradation of memory as we get older. But what is age-appropriate memory loss and what are some of the more common and frequently reversible forms of memory losses, and how do we know it’s not dementia.

So, is it normal memory loss or not? It’s normal to forget the date but it is not normal to not know the month or the year. It is normal to have to search for the appropriate word at times. It is not normal to be unable to hold a conversation. It is normal to occasionally forget someone’s name. (By this standard I’ve been suffering from memory loss since I was about 20 years old.) It’s not normal to not recognize close friends or family members. It’s normal to forget where you put your car keys. It’s not normal to forget what they are used for.

The fact that you’re worrying about some of these mild memory problems is in itself good. It just means that you recognize your memory is not as sharp as it once was. Dementia is a sudden and rapid decline in cognitive ability. It is frequently recognized by everyone except its victim.

Other causes
But before you jump right to worrying about Alzheimer’s, there are several more common medical problems that can cause memory loss and confusion. Most of these are, at least partially, reversible.

One of the most common causes of confusion and memory loss in older adults is what we in the medical field call polypharmacy and what most people call over medication. Some of the most common medications that cause mental impairment are diphenhydramine (more commonly known as Benadryl), pain medications, sleeping pills, medications for dizziness or anxiety, as well as some Parkinson medications. Some side effects of all of these can mimic the symptoms of dementia. This is particularly true if any of these medications are mixed with alcohol. If you’re experiencing some episodes of confusion or memory impairment and you’re on a variety of medications, ask your doctor or pharmacist to review them for potential memory impact.

Other common causes of memory impairment in older adults are dehydration, lack of sleep and lack of exercise. It’s a common misconception that our need for sleep and exercise decreases as we get older. Simple exercises such as daily walking have been shown to increase brain health and memory. The positive effects of exercise appear almost immediately.

Undiagnosed anxiety or depression often can mimic memory loss and dementia. This even has a nice clinical sounding name as the pseudodementia of depression. Poorly controlled chronic diseases such as type 2 diabetes can cause chronic inflammation in the body which can lead to cognitive and memory impairment as well.

It’s also generally believed that poor nutrition can cause memory impairments and a Mediterranean style diet has been recommended as a way of protecting against cognitive decline.

What can I do?

If you have concerns about your memory, of course the first step is to consult your doctor. Ask them to look for and deal with any of those common causes listed above. Be prepared, they may ask you some embarrassing questions about your past. They don’t think you’re a bad person, the only effective way to evaluate problems is to ask the same questions of everyone.

So, from there we get on to what can be done for prevention.

Excessive alcohol use and cigarette smoking have both been shown to have a negative impact on memory and can speed cognitive decline. Try to decrease your alcohol intake to one or two drinks a day and your cigarette smoking to none. There is no safe level of cigarette use. Despite common belief, vaping isn’t safer than cigarette use. Although oral tobacco hasn’t been extensively studied as it relates to memory, in studies related to other diseases it has been shown to increase inflammation and microvascular disease, all of which are known to accelerate memory loss and even vascular dementia.

Plan and implement a regular exercise program. You don’t need to be a marathon runner or a gym rat, you just need to have a steady regular plan. Thirty minutes of moderate exercise four or five times a week will show great benefits. Make sure you don’t get overly aggressive at the beginning and injure yourself. Walking is perfectly adequate for most people and doesn’t put undue stress on your joints.

Sleep like your life depends on it. Set a regular bedtime and stick with it both on weekdays and weekends. Try to get up at the same time every day. Just remember that during normal sleep, memory and learning are consolidated and brain toxins are disposed of. Improved sleep can also help with weight management, blood pressure control and blood sugar control. (More on sleep in a later blog.)

Social interaction has been shown to be as important for preventing cognitive decline as anything else. Strong bonds between family and friends are important for a healthy life. Involvement in churches, social groups and civic organizations are all equally beneficial. People who are socially isolated tend to develop earlier and more rapid cognitive decline. Social engagement also reduces the likelihood of depression.

Activities that require mental engagement, particularly in a social setting, have been shown to delay the onset of cognitive decline and in some cases have even reversed some of the signs in people who have previously been socially isolated.

Activities such as reading, writing, puzzle solving, card games and learning new skills have been shown to delay cognitive decline. For example, one of the things that I have done to try to stay mentally active is starting this blog. Not only am I engaged in researching and writing articles, but I had to learn how to set up and manage a website. Also, I had to learn how to work with voice recognition software because I must admit I’m too old to learn how to type.

Can’t I just take a pill?

For as long as I can remember, the pill to cure or reverse dementia is being tested and will be released sometime soon (it always seems to be within the next year). Unfortunately, most of those have been a disappointment. There have been some medications that have been shown to slightly delay decline, but none have substantially reversed it. And none of these medications have, so far, shown to be superior to correcting polypharmacy, or underlying medical problems, and improving social interactions and mental activities.

The Grumpy Doc says the best way to keep your memory is to stay out there living your life and making new memories. Keep moving, keep thinking, and keep doing. And the next time you see me you can tell me all about it, even if it does take me a while to remember your name.

Anchors Aweigh, Part IV

By John Turley

On February 7, 2023

In History, Medicine, Travel

I reported on board the USS Sanctuary in September of 1969 and went to the personnel office for my assignment. This won’t surprise anyone who was ever in the Navy, but they seemed to have no idea that I was coming. After conferring among themselves, they came back and told me that I would be senior corpsman in sterile surgical supply.

Sterile surgical supply was where we prepared and maintained all the equipment necessary for conducting surgery as well as the sterile equipment used in the clinics and wards. The Sanctuary had several surgical suites that were busy almost all the time when we were on station in support of combat operations. It was a busy place and went through a lot of equipment.

Life on board a Navy ship is a 24 hour a day, seven day a week job. There are no days off when you’re at sea. Fortunately, as a member of the hospital crew, I was what they called a shift worker. Which meant I had a set schedule. Members of the ship’s crew were watch standers. That meant they worked in four hour rotations that changed every 24 hours. We could at least have some type of a routine for awake and sleep time, but for a watch stander the schedule was constantly rotating. As a petty officer and a supervisor, I was exempt from some extracurricular duties such as working on the mess decks and taking part in working parties for regular ship maintenance and supply.

The work was hard and continuous. There was no shortage of casualties in 1969. Our job was to provide direct medical support to our troops in combat. The wounded were flown by helicopter directly from the battlefield to the ship. We got the most severely injured; the ones who couldn’t be effectively treated at a field hospital.

The crew was highly trained and incredibly efficient. From the time a wounded soldier or marine landed on our flight deck it was only minutes until he was in the operating room. The survival rate for the wounded in Vietnam was far greater than it had been in either World War II or Korea. This was largely due to the speed with which casualties were transported to definitive medical care.

We generally didn’t treat civilians, but one day, unbeknownst to us, one of our medevac helicopters was bringing in a pregnant Vietnamese woman. When she was offloaded on the flight deck she was already in labor. They brought her down to the preoperative holding area which was adjacent to our sterile supply room. When there was a heavy influx of casualties, we helped out in the preop area that functioned somewhat like an emergency room.

We were standing there, an anesthesiologist and three corpsmen, trying to figure out how to deliver a baby. Thank goodness the woman took it in her own hands and delivered the baby herself! Of course, that didn’t stop us from congratulating each other about delivering the only baby born on a Navy hospital ship during the Vietnam War. If only all our patients could have turned out so well.

When I remember my time on the Sanctuary, I try not to dwell on the suffering of our patients. Their sacrifices still move me to tears. I prefer to be grateful that I was mostly out of direct combat and to focus the less intense episode that helped us maintain our sanity.

One unexpected benefit of being the senior corpsman in sterile surgical supply was being able to order those supplies. One day while going through the supply catalog I discovered it was possible to order five gallons of pure medical grade grain alcohol. And even better, it required no approval. I also ordered a large five gallon glass beaker. We had wall mounts in our work room where there were glass beakers with soap solution and acetone. We also had an empty wall mount.

The alcohol arrived, along with the five-gallon beaker. I put the alcohol in the beaker and pasted a large poison sign on it. I got green food coloring from the mess decks in return for a promise to share. It’s easy to be generous when you have five gallons. I did have to emphasize that it couldn’t be drunk straight but had to be diluted by fifty percent with fruit juice or soda.

The food coloring gave it an appropriately poisonous appearance. It also gave us the advantage of hiding it in plain sight. I quickly became the most popular corpsman on the ship.

Right after Thanksgiving the CO of the ship issued an announcement that the crew was now authorized to put up Christmas decorations. (I think I’ve mentioned before that sometimes I don’t always think through my wise cracks.) The fact that we were now authorized to have Christmas got me thinking. I made a large sign that said “All enlisted personnel desiring to have a Merry Christmas must report to the ship’s office to obtain a Christmas chit. Personnel having a Merry Christmas without an appropriate chit will be subject to nonjudicial punishment.” A chit was basically the Navy’s version of a permission slip. I thought this was pretty funny. Apparently, the ship’s office did not agree when people started lining up to get their Christmas chits.

This resulted in a stern lecture from our leading chief. It generally consisted of about every third word beginning with the letter F. I was sure I was going to be reassigned, reduced in rank, sent to the brig or something even worse. Surprisingly, after many blistering words, he dismissed me with a wave of the hand. As I was leaving, much relieved, the chief said, “And you can drop off the rest of that grain you got to the chief’s mess .” That depleted my supply and ended my short-lived popularity on the USS Sanctuary.

Right after Christmas, we had the opportunity to have a Bob Hope show on board the ship. Everyone was crammed onto the main deck to watch Bob, a few musicians and some dancers put on about an hour and a half show. I was way in the back as we had all the patients in the front. Bob’s jokes were corny. I’m sure the dancers were pretty (I wasn’t close enough to tell for sure) and the musicians weren’t particularly talented, but a good time was had by all.

Navy ships at sea in a combat zone practice strict blackout at night. Hospital ships don’t. Not only are they painted white, but they are lit up like a cruise ship with large flood lights hanging over the side of the ship to illuminate the red crosses. This illumination led to what quickly became one of our favorite pastimes.

Inshore ocean waters in Southeast Asia are infested with sea snakes and they are attracted to light. One sailor had his parents send him a sling shot and BBs and before long the ship’s rails were lined with sailors firing BBs and watching the snakes rolling in the water. For most of us, these were the only shots we fired in Viet Nam.

Once, while cruising close to the mouth of the Perfume River near Hue City, the ship went dead in the water. The rumor quickly spread among the crew that the NVA had attached a mine to the hull. Everyone rushed on deck to watch as divers went over the side to investigate. Imagine our disappointment when they surfaced dragging a large fishing net that had wrapped around the propeller.

I don’t remember as much about the trip home from Vietnam as I do about the plane ride over. I do remember that as soon as the plane lifted off the ground everyone on board started cheering and applauding and whiskey bottles were passed up and down the aisles. (Perhaps that’s why I don’t remember much about the flight.) Needless to say, it was a very happy trip.

There were other events that I may share at some point, including a misguided trip to Camp Eagle and several port calls to the infamous Olongapo in the Philippines. However, this post has gone on long enough, but I may return later to revisit these memories.

We arrived at Norton Air Force Base, which I now knew was in Ontario, California, not Ontario, Canada. They took us through customs and started searching our bags. I was wondering why, because I couldn’t imagine anything we could possibly be bringing back that would be valuable enough for customs to worry about until I saw them going through bags and pulling out weapons, grenades and even a mortar shell.

This was in the spring of 1970 and the height of the Vietnam War protests. As soon as we cleared customs, they put us in a large auditorium and gave us our welcome home briefing. One of the few things I remember from this is that we were told that if we did not have civilian clothes that we should go to the base exchange buy some and put them on before we got to LAX. Under no circumstances should we go to LAX in uniform because we would be harassed or possibly even assaulted by protesters. This was not quite the welcome home any of us were expecting.

I was on my way to an officer training program and four years in college. I was sure that by the time I graduated and got commissioned the war in Vietnam would be over. But, like many things associated with that war, nothing would ever be certain, and I would see that sad country again.

Critical Thinking

By John Turley

On January 30, 2023

In Commentary, Medicine

Recently I have been reading about the significant increase in childhood diseases that previously had been well controlled with vaccines. There are a number of factors at play here. One is the pandemic which has reduced doctor’s visits and with it some routine vaccinations. But the most significant factor is the resistance among the vaccine deniers not just the COVID vaccine, but vaccines in general.

This is especially troubling to me. These are people, many of whom are well educated, who have chosen not to vaccinate their children or themselves. The majority of these decisions are based on misinformation which has resulted in faulty decision making. I’ve addressed this in a previous post entitled Fake News. However, I would like to address some additional issues related to what is commonly called “critical thinking”. The ability to apply critical thinking would most likely have resulted in a far smaller vaccine denial movement and fewer deaths and disabilities.

Just to start, I’m going to repeat the definition of critical thinking I used in that post. “Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.”

That post was principally geared to critical thinking in adults. I wanted to discuss how to gather information, evaluate it and make a rational decision. I’ve come to realize, that by the time we are adults our method of thinking is very close to being set in stone. If we are to make a significant impact on the way our population evaluates data and makes decisions, it must start with the children.

I believe that the two pillars of early education should be reading and critical thinking. Admittedly, I am not an educator, but I believe if you can read you can teach yourself anything. But you also need the ability to decide what you should believe. The framework for being able to make these decisions is critical thinking.

In some ways critical thinking has been taught in the past, often as the Socratic method. Elements of it have been in specific courses such as philosophy, logic, and scientific investigation. These courses are usually designed for older, advanced students who most likely have already developed these skills or have a natural inclination to pursue such inquiry and evaluation.

For most students, if they haven’t learned how to gather information, evaluate competing ideas and draw coherent, fact based conclusions by the time they are in high school, it may be difficult for them to do so. Critical thinking must be a substantial part of education from the beginning. It cannot be a separate course. It must be integrated into the way every subject is taught. Students should not just be given rote information to be memorized. They should be taught how to think and evaluate and then they should be provided with all the information necessary to make their own informed decisions.

What does this mean? It means that all sides of a topic should be covered. There should be no forbidden subjects. There cannot be an effective analysis of competing information if only one side is presented. This needs to begin in the very first years of education. After all, as Americans we want education not indoctrination.

The ability to develop critical thinking and to make informed decisions requires the exposure to all varying ideas without any value judgment being attached by the teacher. The idea of an academic “safe space” where students are insulated from hurt feelings presupposes that they are unable to evaluate competing ideas and must be protected. This is the very essence of indoctrination and should be an anathema to education.

Children need to learn that the world is not a safe place. If they are not exposed to the competing ideas, how can they be expected to evaluate and recognize the harmful ones? If they are only exposed to one side, they will come to believe that side is the only true side regardless of its value.

I will use myself as an example. There were no efforts to teach critical thinking when I was a student. We were taught that everything presented in class was the right thing, and we were not to question it. Well, this might be true in math and many science classes, but it is not true anywhere else. It was not until well into my adult years that I recognized many of the things I had been taught were the result of societal prejudices and in some cases even ignorance. As a result, like many people, I tended to defend my long-held opinions even after I recognized their weakness.

I was very slow to adopt new ideas. Many of the opinions I now hold are far different from those with which I grew up. Critical thinking was not easy for me; challenging your core values never is. We don’t want our children and grandchildren to have to suffer through the same weakness of thought that we did.

Would the evaluation of competing information that is part of critical thinking have helped prevent the wide scale vaccine denial that we are currently experiencing? Many rumors are being spread about COVID and about the COVID vaccine, just as they have been about other vaccines in the past. There were many rumors that the disease did not exist and that the deaths were faked. These rumors are still on the Internet. They never had any verifiable source and anyone taking the effort to view the data would know that there was a significant death toll early in the pandemic.

The effectiveness of COVID vaccination can easily be checked on the Centers for Disease Control and Prevention website www.COVID.cdc.gov. A study in November 2022 shows unvaccinated Americans had a 16 times (not percent) higher rate of hospitalization compared to the fully vaccinated and a study from January 2022 shows the unvaccinated had a 12.7 times higher COVID related death rate.

There were many reports about side effects of the vaccine. Checking available medical sources, it is easy to discover that while there are some side effects, there are many misstatements or exaggerations about the COVID vaccines. The side effects are similar in frequency to other vaccines and medications in general. Vaccine side effects tend to diminish as the vaccine is improved in subsequent versions. A detailed review of COVID vaccine side effects can be found on www.cdc.gov/coronavirus/2019-ncov/vaccines21.

Social media were quick to jump on every alternative to vaccination. It took very little research to realize that none of these alternatives (think Clorox) had documented medical justification and had never been effectively studied. The supposed studies that were cited were either significantly flawed or could never be duplicated or even be found. Because they had no experiencing in critical thinking, many people accepted the unsupported statements that most satisfied their desires, either politically, socially or medically and adopted them as truth. Unfortunately, this failure in critical thinking resulted in hundreds of unnecessary deaths and severe illnesses.

Anchors Aweigh, Part III

By John Turley

On January 20, 2023

In Commentary, History, Medicine, Travel

When I left my duty station in Key West, the Navy handed me my orders and a check to cover my travel costs. As always, they left it up to me to figure out how to get there. I didn’t worry about that for the first two weeks. I was at home in Charleston, WV, and when I had a week left in my leave, I thought it was time to figure out how to get from Charleston to Norton Air Force Base, where I was supposed to get government transportation to take me to my new duty station, the hospital ship USS Sanctuary that was cruising off the coast of Vietnam.
I asked my father. He had never heard of Norton Air Force Base either and he suggested we contact a friend of his who was a travel agent. So, Dad gave him a call and two days later I went down to pick up the tickets. The agent handed me an airline ticket to Ontario International Airport. While I was trying to explain to him that I wasn’t going to Canada, that I was going to take my orders to Vietnam, he laughed and told me that Ontario was actually in California. It was the closest commercial airport to Norton Air Force Base.
While the Navy had given me money for transportation, it would only cover coach. In those days a coach seat was about the size a first-class seat is today. That flight took me to California where I got a bus to the Air Force base for the government chartered flight to Vietnam.
It was a long trip from California to Da Nang. We stopped in Hawaii to refuel. Unfortunately for us, they wouldn’t let us out of the airport. We were on that airliner long enough that they fed us three times, once on the way to Hawaii and twice between Hawaii and Da Nang. All three meals consisted of baked chicken, peas and carrots, and mashed potatoes. It wasn’t so bad for lunch and dinner but baked chicken for breakfast just wasn’t something I was up for. In typical government style we had three meals supplied by the lowest bidder.
I arrived in Da Nang to discover that the Sanctuary only came in port about every 6 to 8 weeks to resupply and wasn’t due back for three weeks. I got assigned to the transient barracks, where the Navy puts people awaiting further assignment. Sometimes at morning muster (roll call) they gave us jobs such as unloading trucks or doing basic lawn maintenance. Most of the time we were on our own to entertain ourselves.
The transient barracks was in Camp Tien Sha, a Sea Bee run support base. The most popular place on the base for enlisted men was the movie theater. It was open 24 hours a day and was free of charge. You could bring your own beer and they even allowed smoking in the theater. (Everyone smoked in the 60s.) They only had four movies which they ran in continuous rotation. But most importantly, it was the only place on base that an enlisted sailor could go that was air conditioned. Some guys even slept there.
While the camp was in one of the most secure parts of the Da Nang area, occasionally at night the alert sirens would sound. If any place in the surrounding area was attacked everyone got an alert. We would then go out to the bunkers and stand around outside to see if there were any rockets landing close to us. If there were, we would go inside the bunker. If not, we stood around outside smoking and trying to avoid the shore patrol who drove around to make sure we were in the bunkers. Occasionally we could see an explosion or the path of tracers in the air. Mostly we could just hear them. We were never quite sure where they were, but we were fairly confident they weren’t very close.
One of the most entertaining things was watching the TV news reporters. Camp Tien Sha had a weapons repair facility. If you were near it, you could hear machine guns and other weapons being test fired after having been repaired. You could also see tanks and other armored vehicles running up and down their test track. We got a big kick out of watching reporters put on a helmet and a flak jacket and stand in front of the camera while the tanks ran up and down behind them and the machine guns fired and them saying: “I’m reporting from the front lines in Vietnam. You can hear the battle raging behind me “. Occasionally, we would laugh so hard that one of the production people would come over and run us off. I know we ruined more than a few shots.
Eventually I got called to the personnel office and was told that the Sanctuary was due in port that afternoon. They handed me my orders and told me to report on board. I asked how to get to the dock and the personnel clerk just looked at me and shrugged. I eventually found my way to the motor pool and got a ride with a jeep that was heading down towards the docks.
There were several ships in the port at that time. However, the Sanctuary was hard to miss. Unlike other Navy ships that were painted gray, the Sanctuary was painted bright white and was emblazoned with big red crosses on the hull. I walked up the gangway, saluted and requested permission to board. In Anchors Aweigh Part IV I’ll talk more about life on the Sanctuary.

You and Your PSA

By John Turley

On May 19, 2022

In Commentary, Medicine

Several years ago, I received a diagnosis no one wants to hear. Cancer! Prostate cancer to be specific. Thanks to two skilled urologists, I’ve been cancer free for three years.

But it might not have had a happy ending. Please indulge me and let me tell you my story. I think it will be worth your time.

It starts with the PSA. The prostate specific antigen. This is something every man over 40 should know about and every man over 50 should be getting checked.

So, what is the PSA? It is a protein that is produced by both cancerous and normal cells in the prostate gland. It can be elevated by prostate cancer but it can also be elevated by prostatitis (an infection of the prostate) or an enlarged prostate (benign prostatic hypertrophy). It is checked through a simple blood test. Your family doctor can order as part of your annual work up.

What are the recommendations for the PSA? The US Preventive Services Task Force (USPSTF), the group chartered by the federal government to develop recommendations for effective screening of health conditions of the American public has the following three recommendations: (1) consideration of annual screening for men aged 55 to 69 with no family history of prostate cancer; this should be a shared, informed decision between the patient and his physician; (2) for men who have a significant family history of prostate cancer consideration should be given to screening beginning at age 40; (3) for men over 70 years old they recommend against screening for prostate cancer. Please note the phrase “consideration of screening”. This is not a firm recommendation. Unfortunately, some have interpreted that as meaning screening is not necessary.

Their concern about large-scale screening is that it may lead to over diagnosis or over treatment. A PSA test can have false positives that may lead to unnecessary biopsies or surgery. Only about 25% of men who have a prostate biopsy are found to have cancer. Although, it is important to recognize that a prostate biopsy does not test the entire gland. It takes samples from several areas of the gland. It is possible, though unusual, that a cancer could be missed in the biopsy process

A prostate biopsy is graded on what is called a Gleason score. This is a complicated process that involves evaluating the highest grade and lowest grade areas sampled by the biopsy. I won’t go into detail because even medical professionals frequently have to look up the scoring process. The simplified version is that a 6 is a low-grade risk, a 7 is an intermediate risk and an 8 to 10 is a high-grade risk. Originally the Gleason scale was rated 2 to 10. With 2 to 5 being considered no risk. Currently only 6 to 10 is used with 6 being the lowest score.

I’m going to use my personal experience as a way of explaining why I disagree with the current recommendations for PSA screening. The week before my 70th birthday I went in to get my annual physical. In our clinic we have a “birthday panel”, a blood test that we draw for people annually for their physical exam. I had not planned to have my PSA checked since it was not recommended by either the USPSTF or the American Academy of Family Physicians for 70-year-olds. However, it had slipped my mind that a PSA was part of our “birthday panel”.

The urologist and I discussed the options. He told me that the elevation was slight and we could wait and repeat it in 6 months or if I wished we could do a biopsy. Again, not being a wait-and-see kind of guy I opted for the biopsy. After the biopsy my Gleason score was 7 and the pathology report said specifically that it was favorable-intermediate. The guidelines suggested repeating the biopsy again in six months.

As I said, I don’t like to wait. I opted for surgery. I had my prostate removed. I should mention that my family are not wait and see people either and they insisted I choose surgery.

The post-operative report said that there was a high-grade carcinoma that apparently had been missed by the biopsy. It had begun to extend beyond the capsule of the gland. Fortunately for me it had not metastasized and had not spread to the lymph nodes. Had I followed the guidelines and waited another year or even six months for a repeat biopsy, it is possible that the cancer would have metastasized and it could have been fatal.

It is important to recognize that all screening and treatment guidelines are developed on what is considered cost effective medicine for the population as a whole. They are not necessarily what is best for you as an individual. If you have any concerns, you should discuss them with your physician. Never be shy about requesting treatment beyond what guidelines suggest. Just remember, they are guidelines, not hard and fast rules. Take responsibility for your own health and don’t let anyone talk you out of what you think is best for you.

That is the opinion of the Grumpy Doc. If you have any questions, please leave comments on the blog or email me at grumpydocWV@gmail.com.