Apria Healthcare is Crazy!

Names changed for identity protection.

In my almost 8 years of practicing primary care medicine, I have seen plenty of crazy, self-defeating bureaucracies (Lookin' at you, United Healthcare!). But at this very moment, my patient's daughter and I are in the thick of the worst bureaucratic battle of all time.

Apria Healthcare, Inc. is refusing to give my patient oxygen. I have no idea why, except that they are crazy.

My primary care patient Jane lives with her daughter, Louise. Jane has severe COPD and has difficulty leaving the house without supplemental oxygen. She qualifies for oxygen supplementation by Medicare guidelines, but, inexplicably, we cannot get her the oxygen she needs from Apria.

Louise, my medical assistant Cherilyn, and I have been trying to get Apria Healthcare to bring Jane ambulatory oxygen supplies for weeks. (This would mean portable tanks to carry oxygen or a portable oxygen compressor (POC) device that can extract oxygen from the air.) Every time my office sends Apria forms, Apria faxes back that we have not sent the right forms and sends us new ones. This has happened literally ten times this week.

Yesterday, I spoke to an Apria representative who told me that Apria would be sending Jane oxygen tanks in the next couple of days for temporary use. I needed to fill out a form so that she could get a POC for long term use when one becomes available. So I filled out the form.

Last night, Louise called me. A different Apria representative, Robin, called her and told her that Jane does not qualify for a POC. Instead, she needs to get something called a Home Transfill Unit (HTU). This unit extracts and compresses oxygen from the  at home and loads it into reusable tanks for use outside the home. To qualify for this, however, they needed a different form from my office and a record of a visit to my office with measurements of Jane's blood oxygen saturation sitting and walking with and without supplemental oxygen within 30 days. So Louise called me and told me.

This afternoon, I called Apria. I asked for a supervisor. The representative, supposedly named 'Alex,' said none were available, but he would take care of it. 'Alex' told me that Apria had all the paperwork they needed. All that needed to happen for Jane to get the HTU was to pay a fee of $224. I confirmed three times that there was no more paperwork due.

So, I called Louise and told her. She called Apria, and, by coincidence, got 'Alex' on the line. (Alex refuses to give his last name.) 'Alex' told her that she needs to pay the fee, but that I need to fill out a new  form called a WOPD. Louise called back and told me. I asked her to ask Apria to send the form to my e-mail. She did that a few minutes ago. So far, there is nothing in my inbox. 

With Jane and Louise's permission, I have sent this story to the local news station. On Monday, we are going to contact the state attorney general's office and Jane's state rep. THIS IS INSANE!

Addendum: No WOPD form has appeared in my inbox. My e-mail is working, I have gotten multiple e-mails from Louise. Meanwhile, Louise has called Apria again and is currently getting the run-around from reps claiming to be called 'Dick,' and 'Jane.' I am beginning to think Apria has been overrun by a club of sadistic clowns.

Addendum 2: 'Dick' and 'Jane' brought in a supervisor supposedly called 'James.' (How they magically came up with a supervisor after 'Alex' told me none were available is a whole other question.) 'James' told Louise that that they are having "issues" with the document server and that the system is down. They will send the WOPD form to me as soon as it is fixed. Sure they will. Yup.

Apria, the Magic 8-Ball of customer service.

A picture to calm my rage:

#16: Time for flu shots!

Time to get your flu shot! I did, and I'm a doctor. That means I either:

1. am protecting my patients, my family, and myself;

2. somehow missed out on the big meeting all the doctors go to where the CDC reveals its conspiracy to poison everyone's precious bodily fluids; or

3. lied.

You decide.

She puts it better than I can:
http://www.redwineandapplesauce.com/2013/10/28/setting-the-record-straight-dubunking-all-the-flu-vaccine-myths/#mercury

This hawk says, "get the flu shot!"

#15 Warning: Some Drugs Make You Floppy in the Worst Way

This one is a little obscure, but it's a side effect of a common drug and completely avoidable. Read on:

Dear Dr. Tumoriffic,

I'm afraid my iris has gone all floppy. Why did this happen?

Signed, 
Mr. Floppy


Dear Mr. Floppy,

I'm so glad you brought up this subject! Readers, did you know that there is a truly scary way men (and women) can go floppy? And no, it's not polka music. It's drugs. In fact, it's a class of drugs*. And what gets floppy? It isn't your little friend, guys. It's your iris. And in the wrong situation, that can make you blind.

Let me introduce you to FLOPPY IRIS SYNDROME. Floppy iris syndrome--more correctly, intraoperative floppy iris syndrome (IFIS)--is when the muscles of the iris go slack. For most people, it doesn't matter. You won't know you have it, and it won't affect your vision. But cataract surgery could make you go blind.

Patients with IFIS are at high risk of going blind from cataract surgery. However, this is almost always preventable if your ophthalmologist (eye surgeon) knows that you have had certain drugs. Then, they can take precautions. So listen up!

The guilty class of drugs is the alpha-1 antagonists (you don't have to remember that phrase). These are drugs that are sometimes used to treat high blood pressure (which is why some women get IFIS from them), but, usually, they are used to treat benign prostatic hypertrophy (BPH).* This is a very common condition in men over 60.

One of these drugs is much more likely than the others to cause IFIS. It's tamsulosin (Flomax) and probably Silodosin (Rapaflo), because they are very similar. Even a single dose of tamsulosin in a lifetime forever puts you at risk for IFIS. Other common members of the class include alfuzosin (Uroxatral), doxazosin (Cardura), terazosin (Hytrin), and prazosin (Minipres)***. These others may do it, but they're much less of a problem.

Why am I telling you this? Because I saw a patient who had IFIS from tamsulosin and cataract surgery. His ophthalmologist didn't ask about it, and now, he is almost blind in one eye. So, remember this: if you have EVER taken tamsulosin or silodosin, make sure your eye surgeon knows this before you get cataract surgery.

Or, let's be real. Who will really remember these specifics? If you have EVER been treated for BPH, make sure your eye doctor knows before you have cataract surgery, and make sure they know your blood pressure meds! If your parent, aunt, uncle, etc. is having cataract surgery, make sure they tell them. Yes, I am sure almost all eye surgeons remember to ask, but not all of them do.


Oh, and guys, if you have that other kind of floppiness, don't worry. You don't have to tell your ophthalmologist about it. They really don't want to know.

Be well,

Dr. Tumoriffic




* The prostate gland is an organ that produces some of the ingredients of semen, so only guys get to have one.) It is shaped like a doughnut with a very small hole. The prostate is located just at the exit from the bladder, and, through the little hole runs the urethra. Unfortunately, the prostate, like the ears and the nose, continues to grow throughout the lifetime.** Sadly, the hole in the middle does not grow, but shrinks as the prostate grows in on it. That's what alpha-1 antagonists treat.

** As I always tell my patients that if we find the pill that will allow us to live forever, men are all going to look like caricatures of Ross Perot but with basketballs between our legs. Some have proposed that the first person who will live to be 150 has already been born. If that person is male. . .

*** Prazosin is the real weirdo of the bunch. In addition to BPH, it can also treat PTSD and the sting of the Indian red scorpion!

This cat is bored.

#14 A Sacrifice to the Goddess Hernia

Hello readers! I have had the worst writer's block. I have tried every literary laxative in the book (legal ones, that is), and still, I strain to write. But, here is a new one at last.

Dear Dr. Tumoriffic,

I have something bulging in my groin that I can't push back in. Should I come to see you right away, go the emergency room, wait until after my vacation to Newark?

Signed, 
Mr. Bulgepants

Dear Mr. Bulgepants,

Quick answer:

If your hernia is painful, or if it is difficult to push back in, you need to see your primary care doctor or a surgeon right away. If you cannot push it back in, go to the emergency room.

Long answer:

It really depends on what that bulge is. This is a family-friendly blog, so there are some kinds of groin bulge I simply refuse to discuss. However, I will assume that is not where you're going with this. In that case, it sounds like a hernia.

Hernias are one of the oldest diagnosable health conditions. They were known to doctors as far back as ancient Egypt. Hippocrates bestowed the name 'hernia' on the condition in honor of the goddess Hernia, who was the goddess of buds or shoots. Unlike Athena, who burst forth wholly formed from Zeus' head (in the mother of all hangovers), Hernia burst forth from Zeus' left groin during a weight-lifting contest with Atlas.*

A hernia is the extrusion of one part of the body through the tissue containing it. The ones we usually talk about involve the intestines pushing through fascia, the leathery tissue that wraps nearly all of the body and keeps what belongs inside inside. Hernias are extremely common, affecting nearly a quarter of all men at some point over their lifetimes and about 3% of women.

Examples of these kinds of hernia include the ventral (front) hernia, in which the abdominal fascia splits down the middle, and the intestines bulge out, creating a tall, narrow bump in from the middle of the abdomen. Many older men have these, and you can see them if you look for them at the beach. These are usually harmless, though disfiguring.

Another common one is the unmbilical hernia, in which the little weakness of the fascia created by the belly button expands to let out a bump of gut.

Finally, there is the inguinal hernia. Inguinal hernias form because of original sin. Specifically, during fetal development, the testicle must migrate from outside of the abdomen so that it can travel upwards to form most of the male brain. Wait. There is something wrong about that. What I meant is that the gonads are formed in the abdominal cavity.** If the fetus is male, if all goes normally, the gonads migrate out of the abdominal cavity and into the scrotum through a tube of fascia about 4 inches long called the inguinal canal.***

An increase in abdominal pressure from, for instance, trying to lift something heavy like a planet, may push the bowels through the opening of the inguinal canal and even into the scrotum, leading some men to become inappropriately proud of their new anatomy.****

Hernias can be harmless. If it doesn't hurt, and you can easily push the herniated tissue back where it belongs. It can be something to do if you're bored. Some people get them repaired at this stage. That's perfectly reasonable, but usually not necessary.

However, if the herniated tissue becomes stuck (the technical term is 'incarcerated'), it's an emergency. The blood supply to the tissue may be blocked, and the tissue will die very quickly.  The gut is filled with bacteria that are usually quite friendly, but if a piece of gut dies, those bacteria escape into the rest of your body, and you can die in hours.

A hernia can usually be repaired with a very quick procedure. Depending on the type of procedure, patients can often go home within 6-24 hours. They usually can return to light exercise in 1-21 days but have to refrain from heavy exercise (like wrestling a minotaur) for 2-6 weeks.

So, to repeat:

If your hernia is painful, or if it is difficult to push back in, you need to see your primary care doctor or a surgeon right away. If you cannot push it back in, go to the emergency room.

Be well,

Dr. Tumoriffic

PS: Bonus questions:

1.What should you do if you have a hernia that is painful or is difficult to push back in?

2. What should you do if you have a hernia that you cannot push back in?

3. What color is an orange? -Groucho Marx

* Some of the preceding paragraph is actually true.

* Never let your dentist fill your abdominal cavity.

* The inguinal canal is named for the canal that runs through the isthmus of Corinth.  Ancient Greeks who didn't like Corinth referred to the Canal of Corinth as the Inguinal Canal.

* There is an old tale handed down through the generations of doctors in my family. A patient had come into the emergency room with an inguinal hernia so bad that it looked like he had enormous testicles. He was so proud, he wanted to show it to everyone.

This dog is content.

#13 Talking About the Elephant in the Room

First of all, I'm rededicating myself to this blog. I got off-track after getting a little behind on paperwork. A nightly (QHS *) post was too ambitious. However, a weekly (Qweek **) post, maybe with a few extras sprinkled in on easy weeks, should be doable. It will just take a few more decades to have enough to make a book and get to the top of the New York Times bestseller list.

So here goes. . .


Dear Dr. Tumoriffic,

How long should I wait before I call you when I, for instance, feel like I have an elephant sitting on my chest for X minutes, can't catch my breath when I walk, etc.?

Signed, 

Ms. Z



Dear Ms. Z,

You are asking a big, and very important question. Basically, what are some really scary symptoms I should call my doctor (or my priest) about really quickly? The answer will not fit in a single post. It deserves several. So, here we go.


How long should I wait before I call you when I feel like I have an elephant on my chest?

Does 'Z' stand for Zookeeper? If so, there is a finite chance that an elephant is literally sitting on on your chest. In that case, I would call immediately. An elephant on your chest is an emergency.

After quickly consulting online textbook, Up-to-Date, I would advise you to give the elephant's wiggly bits a firm pinch. It will stop sitting on you immediately.*** For the root cause, which is a bigger problem, I might refer you to a specialist, say, an animal behaviorist, who will explore important issues such as, "is it an Indian elephant, or an African elephant," and, "why do you dress so much like a chair?"

But, assuming 'Z' does not stand for Zookeeper, don't even call me. Call the ambulance. 'Elephant on my chest' is one of those phrases causes doctors to pee in their panties. ****

'Elephant on chest," especially when paired with 'can't catch my breath' makes us think of a heart attack and other choice horrors, especially when they run with 'nauseated,' 'clammy,' and 'radiating to the left side of my jaw/running down my left arm,' 'feeling of doom,' and so on. And, even if the feeling in your chest is not akin to Jumbo's butt, there may yet be reason to worry. Nearly any kind of chest discomfort may be a reason to call me. 'Elephant on chest' is a textbook description of a the feeling people get when a part of their heart is not getting enough blood, but your body might not have read the textbook. Women, in particular, may have symptoms that are very hard to interpret. 

On the other hand, there are some nonelephantine forms of chest pain that tend not to upset me. I don't get so freaked out when you describe "a sharp, stabbing pain that lasts a couple of seconds at a time."***** I'm fairly unimpressed when you're 21 and just started doing pushups lately and it hurts particularly badly when you move your arm a certain way. I won't get my hair up in a bunch if you have burning chest pain every time you guzzle a bottle of habanero sauce. It all depends on context and who you are. If you're a 75-year-old chain-smoker with diabetes and a history of heart attacks, even a little chest twinge makes me edgy.


Doctor Tumoriffic, how long should I wait to call you when I have a thunderclap headache?

Once again, don't call me. Call the ambulance. Despite what it sounds like, thunderclap headache is not a symptom of severe gonorrhea. It is a horrendous headache that, instead of building slowly, comes on like a 'thunderclap,' It may be that a blood vessel has burst inside your skull, and it is filling said skull with blood. If a surgeon does not put a hole in your head very quickly, the pressure from all that blood will squeeze your brain out through that hole at the bottom of your skull that's really way too small for the average brain. Bad things happen very quickly--like dying. Don't call me. Call the ambulance.

To be continued. . .

Be well,

Dr. Tumoriffic





* 'QHS' is an abbreviation for a Latin phrase that I use to make me look like a smarty pants even if I don't know what it stands for.

** Qweek is an abbreviation for a Latin phrase that lacks a precise English equivalent but roughly translates as an entire week of bad Star Trek: The Next Generation first season reruns.

*** Side effects of this therapy may include being stomped to death by an angry pachyderm.

**** Other such phrases include 'thunderclap headache,' and 'Medicare Access and CHIP Reauthorization Act of 2015.'

****** That can be significantly scarier, though, when you tell me that is that a guy right in front of you who looks like Freddy Kruger, and he's holding a knife.

Happy Springtime!

#12 Antibiotics: Tell Your Doc if They Aren't Working

Dear Dr. Tumoriffic,

I took my entire course of antibiotics, but my pneumonia is still not better. What should I do?

Signed,

Mr. Cofflin


Dear Mr. Cofflin,

Clearly, you were taking your antibiotic  incorrectly. Much like a fine wine, antibiotics must be paired with the right food.

For instance, you should never pair amoxicillin with red meat. The food will overwhelm the flavor. Amoxicillin goes better with subtle flavors such as a buttered white fish like flounder or sole. You would be advised to wash it down with a pinot grigio or sauvignon blanc.

On the other hand, a bold antibiotic, such as levofloxacin (aka, Levaquin) can be paired with a bold flavor such as grilled sirloin or pasta marinara. Here, you should take your tablets with chianti or red zinfandel.

Azithromycin (commonly found in the Z-pack) is a fine every-day pill. You should take with ale and a hamburger.  Whereas doxycycline is for hard alcohol and beef jerky.


No. Scratch all that. Booze and pills don't mix well.

Most of the time, your antibiotic should make you feel mostly better within 3-5 days. If it does not, or if your infection is worse after 2-3 days, you're on the wrong pill. Also, if your antibiotic is making you projectile vomit or is showing up undigested in your poop, those are also a bad signals.

Surprisingly, I and other doctors sometimes get it wrong. For most respiratory infections outside of the hospital, at least, treatment is based on guesswork. *  It's hard to get a proper culture to identify the exact germ responsible for the infection, and we can usually do pretty well just by knowing which bugs are common the area and which antibiotics tend to work for them.

So what to do then? Give up on antibiotic entirely and go to your local faith healer.

No. First of all, don't just stop the antibiotic without talking to your doctor. Call your doctor. Tell them what's going on so they can replace the antibiotic with one that works better.

I have seen this several times in the last few weeks, and it makes me afraid for my patients. They have come to me much sicker weeks after they finished their prescriptions. (I suspect there is an unusual bug in my community.) One of these days, someone is going to wait too long for the antibiotics to work and they'll get really sick. Now, I'm trying harder to explain this to them.

When you take an antibiotic, most of the bacteria should be killed off in the first few days. You shouldn't stop early, because the rest of the course of antibiotic kills off the stragglers. But if the initial attack is unsuccessful, the bugs are just going to get stronger. Talk to your doctor.

Be well,

Dr. Tumoriffic




* For urinary tract infections, we usually get a culture, so even if we guess wrong to begin with, we can quickly correct our course. However, sometimes, even antibiotics that appear to be effective in culture turn out not to be in real life. That's a whole other subject.

Adorable Sea Otters

#11: The Cold War: You're Not Getting Antibiotics!

This one goes to eleven!

Dear Dr. Tumorific, why do you refuse to give me an antibiotic when I have a bad cold?

Signed, 
Nina



Dear Nina,

I hesitate to answer this, because to do so would break a solemn vow of secrecy that all doctors must make. Furthermore, if I do so, I may be targeted by Big Pharma's squad of flying monkeys, because it is an issue of serious liability to them. But I will tell you, because I believe in the truth even at great personal cost:
Every time a doctor gives a patient with a cold a prescription for antibiotics, there is a real chance that the patient will spontaneously combust. There have been a few famous cases of this, like the talented drummer, Peter James Bond, but there are many less famous ones. As Bond's bandmate, David St. Hubbins said, "Dozens of people spontaneously combust every year. It's just not that widely reported." *

Of course, there are other reasons. . .


[Before I go any further, I have to make a few qualifications. If you have asthma, COPD, a long history of heavy smoking, cystic fibrosis, hereditary or acquired immunosuppression (like from chemotherapy), or have a giant piece of dead skull behind your face, this may not apply to you.] 

Newsflash: There are some medical issues I cannot fix. The common cold is one. Let me illustrate with a fictional scenario:

It's January in Massachusetts. The sky darkens at 4 pm, and the waiting room is packed with patients coughing and sneezing on each other. I walk to the door of exam room 1, and on it is a paper with the name of my patient, the 24-year-old Nigel Tufnel. ** 

I vaguely remember Nigel from his last visit 2 years ago, when he came in to get a health clearance for a bungee-jumping stunt for his heavy metal band. Lower down on the paper, I see written, "complaint: cold." My blood runs cold in anticipation of the battle ahead. I knock and slowly open the door. ***

Nigel looks over at me from the exam table. He appears generally healthy, but his eyes are a little bloodshot, and his upper lip is chapped from wiping. He coughs a loud, juicy cough and greets me in hoarse, broken voice. I avoid his extended hand and make a polite elbow bump.

He has been feeling lousy for three days. He has had a little fatigue and a headache. He has  been coughing all night. He can't stop blowing his nose, and his throat hurts. He has had no sweats or chills, is not short of breath, and he is not wheezing. He has no muscle aches. He might be feeling a little better than yesterday, but he's not sure. 

Nigel has tried three different brands of cough syrup. None of them have worked. I smile sadly. Nigel is doomed. He is doomed for maybe the next few days to cough and sniffle and talk like Tom Waits sings, and there is little or nothing I can do about it. Nigel has a cold. 

I tell him to take a day off and rest. I give him some advice about over the counter medications to make it less unpleasant and maybe prescribe codeine cough syrup. That won't make him cough any less, and it certainly won't fix his cold any sooner, but it will help him sleep. (More about symptomatic remedies another time.)

"But wait, " says Nigel. "Why aren't you giving me an antibiotic? My roommate Derek Smalls had the same thing last week. He went to Dr. Strangelove at the McHealth Stop next to DeMoulas, and Dr. Strangelove cured him with an antibiotic. I think it was called Bubbamycin." This is where the visit gets difficult.  

A cold is a viral upper respiratory infection. Unlike bacteria, viruses do not respond to antibiotics. There are antiviral drugs, but they are not useful against cold viruses. A cold is transmitted when a patient touches something touched by a cold sufferer and then touches their own face. **** One to three days later, the patient gets a cough and/or runny nose and/or sore throat, and/or a bunch of other unpleasant stuff we all know. 

Generally, a cold should start to dissipate after a week or ten days. This can cause a lot of confusion. 

Dr. Strangelove cured Derek of nothing at all. Derek would have gotten better all by himself. But since Derek got better after taking the Bubbamycin, Derek and Nigel logically think the Bubbamycin was responsible. *****

Also, Derek has not told my patient about the very irritating jock itch that happened after Bubbamycin killed off Derek's normal skin bacteria, allowing a nasty fungus to grow. Furthermore, Derek does not know it yet, but the Bubbamycin has also killed off many of his normal gut bacteria. Because of that, in a couple of weeks, Derek will come down with a life-threatening case of Clostridium difficil diarrhea. 

More frightening, every time anyone takes an antibiotic for good or bad reasons, bystander bacteria, or incompletely-eradicated disease bacteria, become a little more resistant to antibiotics. As a society, we are creating bacteria that cannot be cured by antibiotics. There have already been some cases, and we may soon face a post-antibiotic world.

I explain all of this to Nigel. He asks me how I know about Derek's jock itch. I prepare myself for a HIPAA lawsuit. He then says, "But I think I have sinusitis! My sinuses hurt!" 

Nigel isn't wrong. Nigel does have sinusitis. It's probably a viral sinusitis. That's what a cold is. There is a small chance that he has bacterial sinusitis, which also usually resolves on its own within 10 days. Statistically speaking, though, the benefits of antibiotics only start to outweigh the risks after about 10 days. I explain all this to Nigel, watching the clock as it ticks further past the time I was supposed to start seeing the next patient.

Finally, Nigel grudgingly relents. He takes a copy of my custom-made handout for over-the-counter upper respiratory infection treatments (See below! ******) and checks out. I spend the next half hour documenting and billing the visit in the electronic medical record.

This is a common scenario. Doctors find it very difficult. If we give the patient antibiotics, the patient leaves happy and gets well (with the help of their own immune system) and thanks us. Saying 'no' tactfully takes precious time, and the patient may still be annoyed with us. It may also detract from our scores on patient satisfaction surveys, which can lower our pay.

But being a good doctor may mean disappointing the patient. So, sorry Nina. No antibiotics for your cold.

Be well,

Dr. Tumoriffic




PS: By the way, Nina, the same basically goes for the flu. Technically, there is medicine for it, but it's not very effective, it's expensive, and has lots of side effects. I would only use it for very sick patients since it does slightly decrease their risk of dying from the flu.

PPS: Don't buy combo cold products. They're overpriced combinations of medications that you can buy more cheaply individually. If you must get one of these combis, look closely at the identity and dosage of each component before you take a different medication, such as acetaminophen (aka Tylenol), that may actually be the same as one those included. Otherwise, you may overdose. (Also, by the way, never take more of a medication that is recommended on the bottle unless your doctor says so. Just because it's over-the-counter does not mean that it's safe to take it like candy. I've seen that, and it can be ugly.)


* http://www.seeker.com/mysterious-death-ruled-spontaneous-combustion-1765446824.html

** I have no patient with the name Nigel Tufnel. In fact, I have never met such a person.

*** Never tell your doctor you are coming in for a 'cold.' It's like announcing that you're going to waste their time. That can be a dangerous distraction when what you thought was a cold turns out to be a pneumonia. That has happened in my experience.

**** So wash your hands, all of you! The flu, on the other hand, is transmitted through the air, so you should try not to breath when you are around other people during the winter.

***** This is why we need statistical analysis in medicine. Without being able to compare at many different cases of patients who have gotten better from a given condition, we have no way of knowing whether the remedy they used had anything to do with their getting better. Eons of worthless remedies have flowered, not because people in the past were stupid, but because there was no way to distinguish between a cause and a coincidence.

****** 

Advice for Allergies, Colds, Coughs, and Sinusitis

Nearly all short-term upper respiratory illnesses are viral or allergic, and not bacterial.  Viruses cause infections, but we have no treatment for them. Therefore, antibiotics are usually more likely to give you diarrhea or put you at risk for a more dangerous infection than make you better. The following nonprescription treatments may make your illness less unpleasant:

1. REST!  Take a day or two off if you can.

2. Neti-Pot or Sinus Rinse:  Use as often as you want and at least twice daily when you are sick. This is very important. Salt water in a teapot-like container or a bottle flows in one nostril and out the other or the mouth, clearing out nasal discharge and preventing serious bacterial infection. (Best to use boiled tap water or distilled. Most places are probably safe, but you never know.) This is not the same as saline nasal sprays, which can help, but not nearly as much.

3. Honey: Spoonfuls of any kind of honey sooth the throat and may help with coughing. You can also gargle with warm water and honey mixed with salt and baking soda. Go easy on the honey if you have diabetes.

4. Cough drops or hard candy: These, especially the ones with lidocaine, may sooth a sore throat and suppress a cough.

5. Humidifier: Useful for all respiratory conditions during cold weather. Clean frequently to avoid fungus, or use a hot water humidifier.

6. Steam: either buy a sinus steamer from the pharmacy or boil pot of water, put on the table and lean over it with a towel over your head and the pot and breath until the water stops steaming. This will moisten your airways and help clear dried mucus.

7. Over-the-counter nasal steroids: Fluticasone (Flonase) and triamcinolone nasal spray (Nasacort) are very helpful for allergies and sinusitis. They are much safer than oral or intravenous steroids. Do not let the spray get into your eyes. Do not use without a doctor's advice if you have glaucoma.

8. Oxymetazoline nasal spray (such as Afrin): This works immediately to stop congestion and open the sinuses. 2 puffs every 12 hours FOR 3 DAYS ONLY.  Longer use can make stuffiness worse! You may use this at the same time as other nasal sprays if your doctor prescribes them. Do not use this if you have glaucoma. 

9. Pseudoephedrine (You have to ask the pharmacist for this directly): This helps dry up mucus, and open sinuses. It may cause insomnia, anxiety, or cardiac arrhythmias. Do not use if you have severe hypertension.  Elderly men or men with benign prostatic hypertrophy (BPH) should avoid pseudoephedrine as it may worsen urinary symptoms.

10. Antihistamines: These are mostly for allergies. They help dry up nasal secretions and decrease congestion.  Older antihistamines such as diphenhydramine (aka Benadryl) are stronger, but may make you drowsy. Avoid them if you are over 75 as they may cause confusion. The newer antihistamine, fexofenadine (Allegra), is less likely to cause this.  Elderly men or men with BPH should avoid antihistamines as they may worsen urinary symptoms.

Upper respiratory infections usually improve by 10 days or so whether or not you take medicine for them. If you are sick for more than 10 days and are not improving, if have a fever >101 for more than 3 days, if you have difficulty breathing, if you cannot keep down fluids, or if you suddenly become much sicker after mostly recovering, give us a call or visit.

This sneezing marine iguana is not getting antibiotics!

The iguana is actually sneezing. For marine iguanas, sneezing is the equivalent of urinating. They sneeze out extra salty fluid to maintain a proper salt balance in their bodies. So this is also a picture of an iguana taking pee.