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Dr. Zach’s Guide to Summer Health

BT Montreal | posted Tuesday, May 23rd, 2017

Being outside and active is healthy


Skin protection –

Sun exposure is the greatest cause of skin damage with time (aka photoaging), caused by uv radiation

Sun exposure is the greatest cause of skin cancer


Skin cancer:

Squamous cell cancer (16%)

Basal cell cancer (80%)

Malignant melanoma (4% but >75% of skin cancer deaths)


ABCDE rule for skin cancer, esp melanoma


B — Irregular borders

Colour – blue black, multiple colours

Diameter – greater than 6mm (pencil eraser)



Highest UV between 10am and 4pm

Shade, hat, clothing, esp with UV protection factor (ore tightly woven)


Typical car, home, and office windows block most UVB rays but a smaller portion of UVA rays


Sunscreen – get broad spectrum upf (uv protection factor) (UVA and UVB).  spf reflects uvb protection.  Use 30+

Uva skin aging wrinkling some skin cancer

Uvb main cause of sunburn and cancer

Both lead to skin aging eye damage (cataracts mainly) skin cancer


Reapply sunscreen every 2 hours and after swimming (some are water resistant)


UVB does induce production of vitamin D.  Can get it via diet or supplements.  And even with sunscreen you will get vitamin D.

Foods with vitamin D:  Fatty fish, like tuna, mackerel, and salmon.

  • Foods fortified with vitamin D, like some dairy products, orange juice, soy milk, and cereals.
  • Beef liver.
  • Egg yolks.


Sunglasses should block 99% to 100% of UVA and UVB rays


Avoid tanning beds — >90% UVA, rest UVB.  exposure to tanning bed in youth increases risk of melanoma by 75%


If you “need” a tan use a cream (stains the skin)



Risk factors for heat illness – young and old, chronic medical conditions, certain medications

When high humidity sweat will not evaporate, so less able to cool.  Other conditions predisposing are obesity, fever, heart disease, mental illness, poor circulation, sunburn, alcohol.

Heat cramps, heat syncope (passing out from low blood pressure from relative dehydration), heat cramps from loss of fluids and electrolytes, heat exhaustion (weakness, lightheadedness, fatigue)

Heatstroke – life-threatening emergency that can damage almost every organ (brain, gi tract, liver disease, kidney damage).  Treated with cooling, fluids


Dress lightly, limit physical exertion, air conditioning, fluids — bring water drink regularly.  Avoid alcohol, stay in the shade.  Keep urine clear


Insect bites – most are not harmful though some people are allergic.  Some spiders can cause quite severe local reactions.

Mosquitos can carry serious diseases – west nile virus (here), dengue, ebola, chikungunya

WNV- 1 in 2-300 people infected with WNV get sick.  Only in summer.  Symptoms – vomiting myalgias sore throat fever chills

Avoid mosquito bites – DEET repellent, don’t leave sitting water.  Consider netting.  Peak biting times are dawn and dusk/early evening.

Tick bites – deer tick carries it.  3 stages (rash, flulike, headache arthritis). Tx with abx.  Prevention with long-sleeves, light clothing, DEET-containing repellent, keep grass trim, check pets

Hymenoptera (ants, bees, wasps, spider – a type of insect) stings – In most people they cause pain and local swelling.  Some people have anaphylactic allergies which is life threatening.

Noisy activity, bright coulours, perfumes, may incite stings

Remove stinger or tick from skin


Animal bites – dogs cats rodents (rat mouse hamster squirrel gerbil) primates farm animals humans

Dog bites – 5-10% infection (12-30% in hand)

Cat bites – 30-50% infection

Rodents – low risk of infection

Primates (chimps, apes, monkeys, humans) – high risk of infection.  Human bites to hand 25-50% infect

Rabies – virus, from bites more than scratches

Headache runny nose fever sore throat muscle aches upset stomach back pain spasms

High risk animals for rabies — fox raccoon skunk bat coyote

Post-exposure prophylaxis

All about Mom’s Health

BT Montreal | posted Wednesday, May 10th, 2017


  1. Having children earlier and having more children decreases the risk of breast cancer (due to decreased menstrual cycle hormone exposure) (but shed pregnancy weight — obesity increases risk of breast cancer). Breastfeeding also decreases risk of breast cancer
  1. Having children lowers the risk of ovarian cancer and endometrial cancer.

Hemorrhoids: Motherhood increases the risk of hemorrhoids.

Urinary incontinence:  Motherhood increases the risk (the more kids the greater risk) (Majority of women improve their diet, at least initially)

Postpartum depression: 75-80% of new moms get baby blues; 10-20% of new moms get PPD

Happiness:  People with children happier?  Not necessarily.  They have more highs and lows.  Much is tied to other factors — marital status, economic and work status.   Single parents have a tough time. Countries with social policies allowing parents to better combine work with family make happier mothers.

Sleep:  New parents are sleep deprived

Expectations:  Lots of pressure to be the perfect mom

Infections:  Moms of kids in daycare are exposed to many infections, mostly viral

What can be done:

  1. For the non-moms — help out!  Let mom sleep, make food, do laundry, esp with newborns.  Give mom a break.
  2. For moms — find ways to take care of yourself — get a babysitter and sleep, eat well, exercise, see a friend.  You can better take care of others if you take care of yourself.  Give yourself a break.
  3. Not worth it to have a kid for the health benefits but if you want one, do what you need to take care of yourself and your baby.

Optimizing your visit with the doctor

BT Montreal | posted Tuesday, Apr 25th, 2017

Optimizing your visit with the doctor

Courtesy: Dr. Zachary Levine, emergency physician at McGill University Health Centre


Average amount of time doctors spend with a patient is less than 15 minutes (this is decreasing)

Female doctors spend a bit longer than male doctors on average

Studies have found an association between shorter doctor visits and increased rate of medication prescription


In order to get the most out of a visit, plan ahead:

You have your agenda (particular concerns), doctor has theirs (screening, preventive health)

  • Pick your top 1 or 2 concerns:
    • Think about them — description, what brings them on, makes them better
    • Research (wisely) if you know your diagnosis.  What can you do to help?  What don’t you understand?  What is the doctor’s experience with this condition, advice
  • Ask specific questions
  • Be an active partner — what can you do?
  • Do you need that test/pill?


Bring lists:

  • Medication List (DSQ)
  • Past medical history
  • Past surgical history
  • Allergies


If you’re going to the ER

  • CTAS — triage — life threatening first, other things wait
  • Typically quieter early weekend mornings
  • Ambulance doesn’t speed up being seen but if you’re not well don’t drive yourself, ambulance can begin treatment
  • Squeaky wheel hard to ignore but doesn’t necessarily get faster or better care
  • Care order should be only based on acuity
  • Best to go where you’re known
  • Consider calling health line (but their threshold has to be low to send you in)
  • Think about your goals and what you want done

Medical symptoms you should not ignore

BT Montreal | posted Monday, Apr 10th, 2017

Almost any symptom can indicate something serious, but it doesn’t mean they are.  For example, back pain is from a benign cause 90% of the time, but it can be life threatening.  Doctors use clues to give us evidence of whether symptoms are of something serious.


Here is a list of symptoms you should not ignore:

  • Chest pain — perhaps this is obvious, but not to everyone.  Don’t chalk it up to heartburn unless you know it’s heartburn.  If it’s a heart attack, you need to know.  Symptoms associated with cardiac chest pain include sweating, shortness of breath, dizziness, and palpitations.
  • Shortness of Breath — again, maybe obvious.  Don’t decide “it’s just a cold or asthma,” especially if you don’t have asthma!  It could be your heart, or your lungs.  A blood clot in the lungs, aka a pulmonary embolus, can be deadly.
  • Sudden severe headache — sometimes a headache is just a headache.  But if you don’t usually get headaches and you get a sudden one that is severe, get it checked out.  It could be a bleed in your brain.
  • Rapid, unexplained weight loss — If you lose weight for no reason, ie you are not eating less, or exercising more then you need to find out why.  It may be that you are not absorbing food properly, or it may be a symptom of cancer.
  • Excessive urination — When we drink alot we urinate alot.  That’s normal, as the body keeps a balance of fluids.  However, urinating frequently may indicate other things, such as infection (usually accompanied by burning on urination), or diabetes, especially if accompanied by unexplained, excessive thirst.
  • Bleeding — normally we bleed when injured.  And healthy blood makes clots to stop bleeding.  However, if you are bleeding for no reason it should be checked out.  You may have a blood disorder.  Blood in the stool or black, tarry stools, or vomiting blood means bleeding in the gastrointestinal tract.  This can be caused by benign entities such as hemorrhoids, but can also be caused by cancer, and the bleeding can sometimes be severe.  Blood in the urine needs to be checked.  It can be caused by stones and infections, but also by cancer, of the bladder or the kidneys.  Coughing up blood may occur with infection (in small amounts) but more serious causes need to be ruled out, such as pulmonary emboli and cancer.  Postmenopausal vaginal bleeding needs to be checked out to rule out a serious cause, such as cancer.
  • A swollen painful leg (without an injury) — Leg swelling can result from injury, to be sure.  But a single swollen painful leg is concerning for a problem with circulation, such as a blood clot.  Bilateral swollen legs can result from a heart problem or something blocking the flow of blood back into the pelvis from the legs.
  • Severe abdominal pain — Sometimes benign conditions, such as gastroenteritis, can cause severe abdominal pain.  However, some life-threatening conditions can cause it as well, such as abdominal aortic aneurysm (swelling of the large blood vessel in the abdomen, potentially bleeding), ischemic colitis (lack of blood to the bowel, which can cause the bowel to die), appendicitis or cholecystitis (gallbladder inflammation, which often requires surgery to treat).
  • Severe back pain — Most people experience back pain at some point in their lives, and the majority of back pain is musculoskeletal in nature (due to muscle strain etc), benign, and resolves without any treatment.  Severe back pain may be from kidney stones, which are usually benign, but you need to check it out.  It may also represent serious infection or cancer.  The red flags doctors use to indicate potentially serious back pain include duration of more than 6 weeks, age younger than 18 or older than 50, trauma, a history of cancer, night sweats, fever, chills, weight loss, night pain, IV drug use, and neurological symptoms such as weakness and numbness in the legs or in the saddle area, or urinary retention or incontinence.
  • Flashes of light — seeing flashes of light may indicate an oncoming migraine, but they may also be a symptom of retinal detachment, an eye emergency that needs emergency treatment.


All of the symptoms above may result from benign causes, but maybe not.  So get them checked out.

Dr. Zach’s Guide to Dr. Google

BT Montreal | posted Monday, Mar 27th, 2017

Dr. Google — Using the Internet to improve your health


Unlimited information available at the click of a button.

People are getting informed about their health.

One in every 20 Google searches is health related

Pew research ctr:  80% of ppl have looked up health info online


Internet has info about conditions, health maintenance advice, and even programs that will try to diagnose you.


Self-diagnosis? Regarding online symptom checkers – Harvard study reviewed 23 symptom checker sites and found that they are not good at triaging or diagnosing — they err on the side of caution (can’t say it’s nothing if it’s something) and they only got the right diagnosis 34% of the time.  23 websites, 45 vignettes half common.

BMJ 2015;351:h3480 doi: 10.1136/bmj.h3480

Conclusions Symptom checkers had deficits in both triage and diagnosis. Triage advice from symptom checkers is generally risk averse, encouraging users to seek care for conditions where self care is reasonable.


So be careful about symptom checkers.  At best they can give you a list of possibilities.


Knowledge is power.  Good to be a partner in your healthcare — better to be active than a passive recipient.  The doctor has a limited time to explain. More info empowers patients — doctor as guide




Is the information real or “fake news”?  Who is writing it?  Who is paying for it?  What is their motive?

—-Be careful of miracle cures that cost money


Another problem is that we tend to search out things that we agree with or want to believe and dismiss the rest


So where do we go for valid information:

–Governmental (eg/ health Canada, Canadian public health agency), sites that end in.edu, .org

–Mayo, harvard



In some countries they’ve curated bona fide health info to pop up with searches eg/ Australia

What about online forums?  They are good for support, community (you are not alone) but careful to make sure they relate to you.

Dr. Zach’s Guide to Kidney Stones

BT Montreal | posted Tuesday, Mar 14th, 2017

I am a 50 year old man who experienced my first kidney stone last week.  The pain was excruciating.  The doctor sent me home with some pills and a follow-up but I want to know — will the stone pass on its own and will this permanently damage my kidneys?

Kidney stones are very common, with a lifetime prevalence of 12% in men and 7% in women.  The risk is higher if you have relatives with kidney stones.  They are known to cause very severe pain which often requires a visit to the ER to control.

In general, kidney stones are not considered to be a common cause of kidney failure.  The risk of kidney stones causing kidney failure is higher in people with diabetes, only one kidney, pre-existing kidney disease, and polycystic kidneys.

Most kidney stones (85%) pass on their own.  The chance of passing depends on the size (less than 6 mm have a better chance of passing), shape, and orientation of the stone.  In the ER the doctor gives medication to control the pain and checks to make sure that the kidneys are functioning well and that there is no infection.  If the stone cannot pass on its own then a urologist will determine the best way to help it do so.  Methods include lithotripsy (using electromagnetic shock waves to break it down), ureteroscopy (using a scope to remove it), or percutaneously (through the skin).

What is important if you have kidney stones is to have follow-up with a doctor after the acute episode, for two reasons: first, the doctor can determine what kind of stone you have and recommend ways to decrease your risk of recurrence.  In general it is wise to drink a lot of fluid and, for calcium (the most common type) stones have a low protein and low salt diet.  In addition, the doctor can check your risk factors for kidney disease and control them early.  This will protect your kidney function for the future.

Travel Advice from Dr. Zach

BT Montreal | posted Wednesday, Feb 8th, 2017

Plan ahead

  • Make sure you have medical insurance
  • Hopefully you won’t need it but if you don’t have it you’ll probably need it
  • Affordable, shop around
  • Make a timely Pre travel appointment with your doctor (less than 50% of ppl do)
  • You could need vaccinations – routine or otherwise – may need 4-6 weeks for this
  • Vaccines are individualized and depend on where you’re going.  Available:  yellow fever, meningococcal, typhoid, hep A, hep B, rabies, cholera, japanese encephalitis
  • Routine vaccinations — influenza, tetanus, diphtheria, pertussis, mmr, polio, varicella


Consider safety while away

  • Hand hygiene
  • Sun protection for eyes and skin — sunglasses, sunblock, sun shirts, hats, mosquito protection
  • Driving — intl license, be careful
  • STI’s – bring protection


Top things think of if you’re travelling to Mexico, Caribbean, or southern US this spring break:

  1. a) Traveller’s Diarrhea
  • Most common illness in travelers
  • Develops within 10 days of return
  • Variety of bacterial (etec most common), viral, parasitic (tend to persist longer) organisms
  • Prevention is key — eat only throoughly cooked hot foods, fruits you peel, pasteurized dairy.  Bottled drinks without ice, use straw
  • Freezing does not kill the diarrhea-causing organisms.  Alcohol does not sterilize them.  Fruit salads, lettuce, chicken salads unwise
  • Water purification — boiling for 3 min then cooling to room temp.  Adding 2 drops of 5% bleach to a quart of water will kill most bacteria in 30 min.  Adding 5 drops of tincture of iodine to a quart of water will kill bacteria within 30 min.compact water filters can be used
  • Chemoprophylaxis not recommended
  1. b) Chikungunya, Zika viruses – mosquito avoidance
  • Avoid feeding time (malaria Japanese encephalitis, west Nile virus between dusk and dawn; for dengue, chikungunya, zika, yellow fever during daytime)
  • Wear clothing that covers skin
  • Insect repellant.  DEET (there are others that work)  don’t saturate the skin.  Not under clothing.  Avoid eyes mouth genitals, wounds
  • Treat fabrics with insecticides’
  • Screens, tents
  1. c) Malaria (DR, Haiti) – chemoprophylaxis, mosquito bite avoidance
  • Depending on what else you do — diving barotrauma, STIs


2.     Staying well en route and coming home:

Air travel

  1. risk of VTE (blood clots) on flights of 4+ hours. Consider asa, compression stockings.  Get up and walk.
  2. Decreased paO2 in planes – may cause fatigue, “foggy brain”, headache.  Most ppl are fine but if sig heart lung dz, anemia, talk to your doctor
  3. It’s dry up there — drink
  4. Air pressure changes can cause ear pain in people with resp tract infections with blocked eustachian tubes — chew, yawn, suck sweets, valsalva, decongestant/antihistamine
  5. Jet lag — Curtail coffee, stay hydrated, Avoid or limit alcohol inflight, Try to sleep on the plane, Use sleeping pills wisely, Get outside, light, Adjust your clock, exercise
  6. Sharing germs — wash your hands!


Dr. Zach’s Guide to Postpartum Depression

BT Montreal | posted Monday, Jan 16th, 2017

By Dr. Zach Levine, ER physician, MUHC



A postpartum (PP) mood disorder begins within one-year of delivery with most occurring within four to eight weeks and lasts two weeks.

Distinguished by baby blues (BB) which is sadness interspersed with happiness, onset usually two-to-three days with a peak of seven-to-10 days.  Subsides within two weeks.

Baby blues affect 75 to 80% of new mothers, while 10-20% of new mothers are affected by postpartum depression.

Note — other postpartum mental health problems may be associated — anxiety disorders (PP Panic disorder, PP OCD), PP psychosis

Symptoms of PPD

  • Sadness
  • Crying
  • Insomnia
  • Appetite change
  • Difficulty concentrating
  • Feelings of worthlessness
  • Racing & obsessive thoughts
  • Anger
  • Fear
  • Guilt



  • Biological –  sudden drop in hormones (estrogen progesterone neurotransmitters) at delivery
  • Genetic – predisposition to mood disorders
  • Psychological – coping mechanisms, myths (below)


Freedom, identity, control, slim figure, feeling of unattractiveness. Usually comes down to a combination of factors.

  • Social – lack of support systems
  • Infant-related – even healthy infants require regular feedings around the clock and care, along with regular household needs. Unhealthy infants cause extra stress, as well as premature, those with colic.


The problem with myths is they don’t help – not meeting them can lead to guilt and shame. The fairytale image can be problematic: A happy mother, intuitive mothering, unremitting love, perfect baby, fathers being equally involved, being the perfect mother.


Risk Factors for PPD

  • First time mother
  • ambivalence about the pregnancy
  • History of mood disorder
  • Lack of social support
  • Lack of stable relationship with partner or parents
  • Unrealistic expectations about parenthood
  • Previous PPD


  • Therapy — individual or couple of group
  • Support groups
  • Practical help (every visitor brings food or does a load of laundry)
  • Medications

It is common and it is treatable and you are not alone.

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