The health and social issues with tattoos

The health and social issues with tattoos

Greg Hall, MD

Almost half of people between 18 and 35 have tattoos, and almost one in four regrets it, according to a 2016 Harris Poll. Based on an estimate of about 60 million people in that age group, that would mean that about 7.5 million people have tattoo regret.

As a primary care physician, I’ve noticed anecdotally that many of my younger patients have regrets about their tattoos. When I ask about them, many say that they got them when they were young, and at the time put little or no research into the decision.

With no source (reliable or otherwise) of tattoo information to suggest to my patients, I began to investigate the topic myself. My goal was to write a quick reference for teens that reviewed the health and social issues they might encounter after getting a tattoo.

What I found was myriad unexpected and sometimes shocking concerns that everyone should know. To my surprise, there were a host of reports of ink complications, infections, toxin effects, scarring, burns, chronic irritations and much more.

The ink goes more than skin deep

Iron Oxide Oxide RedAmong the concerns are the long-term effects tattoo inks can have on the immune system, pathology specimen interpretation and other unforeseen health complications.

Certain tattoo inks can be toxic, with some containing carcinogenic compounds, a 2012 Danish Environmental Protection Agency found. In fact, one in five tattoo inks contained carcinogenic chemicals, and a vast majority of the inks tested did not comply with international health safety standards for ink composition, an Australian government-sponsored study found. Even more concerning, carcinogens were identified in 83 percent of black inks – by far the most popular color for tattoos.

The European Society of Tattoo and Pigment Research was established in 2013 with a mission of educating the public about the “fundamental facts about tattooing” which many in the younger generations ignore. That group found barium, copper, mercury and other unsafe components in tattoo inks. Their research also found a disheartening mismatch between the listed ink container contents and its actual chemical composition found on testing.

More recently, the Food and Drug Administration has become more involved with tattoo inks, stating “Many pigments used in tattoo inks are industrial-grade colors suitable for printers’ ink or automobile paint.” Like the studies started overseas, the agency is now examining the chemical composition of inks and pigments and how they break down in the body, as well their short- and long-term safety.

Tattoos have led to errors in medical treatment, testing

Metal-based ink tattoos can react with magnetic resonance imaging studies. For instance, two case studies detail patients who suffered MRI-induced burns in their tattoos that were attributed to iron compounds in tattoo pigments. Radiologists say this magnet-based reaction is rare, but some have suggested simply avoiding iron-based tattoo inks.

Pathologists, meanwhile, are reporting tattoo ink in surgical biopsy specimens of lymph nodes. For instance, a 2015 report in the journal Obstetrics and Gynecology detailed the case of a young woman with cervical cancer which doctors believed had spread to her lymph nodes. After surgery to remove the nodes, they discovered that what appeared to be malignant cells in a scan was actually tattoo ink. A similar misdiagnosis occurred in another patient with melanoma.

And then there are the infections

Hep-CThe most common infections associated with tattooing involve staphylococcus aureus or pseudomonas bacteria arising from poor skin preparation or equipment sterilization. “Staph” skin infections can become serious and even life-threatening, as antibiotic-resistant strains become more prevalent.

Three percent of tattoos get infected, and almost four percent of people who get tattoos recount pain lasting more than a month, a 2015 study from Tulane University School of Medicine found. About 22 percent of participants with new tattoos reported persistent itching that lasted more than a month.

A spate of mycobacterial skin infections in 22 people across four states in 2011 and 2012 was tied to a few specific brands of ink. The Centers for Disease Control and Prevention, in conjunction with local departments of public health, were able to contain these infections through intense tracking and investigation.

More serious tattoo-induced skin disorders like sarcoidosis, lichen planis and lupus-like reactions are increasingly reported in current literature. These skin problems can be more long-lasting and leave permanent scarring.

A study reported in Hepatology found that “tattoo exposure is associated with HCV (hepatitis C virus) infection, even among those without traditional risk factors. All patients who have tattoos should be considered at higher risk for HCV infection and should be offered HCV counseling and testing.”

Hepatitis, which is 10 times more infectious than HIV, can be transmitted through needles used by tattoo artists. It is the reason the American Red Cross restricts blood donations from individuals with newer tattoos done outside of regulated tattoo facilities.

A study from Tulane University added credence to these blood donation restrictions by showing that 17 percent of all participants had at least one tattoo done somewhere other than a tattoo parlor, and 21 percent admitted to being intoxicated while receiving at least one of their tattoos.

A youthful decision with adult implications

The primary reason Harris Poll respondents reported tattoo regret was they “were too young when they had it done.” The second most common reason, which coincides with the first, is the tattoo “didn’t fit their present lifestyle.”

Whether a tattoo depicts a name, a person, a place or a thing, its meaning and perception are in constant flux. Eric Madfis and Tammi Arford, writing about the dilemma of symbols and tattoo regret, note that “Symbols are dynamic in that they are time-specific, ever-changing, and always in a state of gradual transition.”

Tattoos have a different meaning depending on the interpreter, their relative history and knowledge, and they are dynamic because they can take on different meanings through time and experience. The first person to get a barbed wire tattoo on an upper arm could be seen as clever, inventive, unique and trail-blazing. The one-hundredth person to get the same tattoo was none of these things, and with time, if either was seen in public, both would receive the same reaction.

The “emotional response in the beholder” of any given tattoo can be based on “social stratification” and is not consistently predictable, according to Andrew Timmings at the University of St Andrews in the United Kingdom. Their interviews of hiring managers showed that tattoos can actually hurt job prospects.

Another study, at the University of Tampa, confirmed that 86 percent of students believe that having a visible tattoo is a detriment to their business prospects.

Researchers at the Harris Poll found that older respondents are less tolerant of visible tattoos as the prestige of the job position rises. While a vast majority of people age 51 and above are comfortable with professional athletes having tattoos, the acceptance decreases significantly when doctors, primary school teachers and presidential candidates are included.

Understandably, people who have many friends and family with tattoos are generally less stigmatized regarding their tattoo, and tend to suffer less tattoo regret, a study in The Social Science Journal reported in 2014. But the study also found that when tattooed respondents were exposed to individuals without tattoos, like in the workplace or institutions of higher learning, more stigma victimization occurred, and those impacted were more likely to suffer regret and ponder removal.

People often regret getting married when young, just as they do with tattoos. From www.shutterstock.com

Getting a tattoo, which is akin to a life-changing (and body-changing) decision, when young is really no different from getting married young (32 percent regret rate) or choosing a college major (37 percent change rate). For many, making a major decision when young is rife with regret. The difference with tattoos is having to face that regret on a daily basis.

As the pure number who have tattoos grow, the market for getting these tattoos removed has also found its niche. Laser tattoo removal services have rapidly grown across the nation and have become a multi-million dollar business, with additional potential for growth as the younger, highly tattooed, generations age.

But some problem tattoos can’t be removed

Laser with screenCurrent lasers still have limitations in the colors they can erase with added difficulty stemming from more vibrant tattoo colors. Darker pigmented people tend to have less success with certain lasers and require more sessions to avoid skin damage.

Because the laser shatters the pigment particles under the skin for removal by the body, the issues with infections, scarring and the ink spreading become a concern again. Tattoos covering extensive areas of the body are simply too large to tackle in one session, and could take years to remove.

Laser complications include pain, blistering, scarring and, in some cases, a darkening of the tattoo ink can occur, according to dermatologists.

As technology and the demand for tattoo removal advances, some of the limitations of current lasers will shrink. Newer, easy-to-remove inks are being patented, which may represent a healthier approach due to biodegradable ingredients, and a more predictable laser response. Picosecond lasers are also dramatically decreasing the number of sessions needed in select populations.

Teens Tattoos Piercings Front Cover aEducation is the key

With such a large number considering tattoos at a young age, informing young people of the health and social risks could help them avoid tattoos they may come to regret. Adding permanent body art education to health classes could mitigate some of these mistakes and decrease later regret.

The ConversationGreg Hall, Assistant Clinical Professor, Case Western Reserve University

This article was originally published on The Conversation. Read the original article.

Do Great Music Artists Die Young?

With the startling death of Prince at the age of 57,

many began to reflect on the seemingly ‘premature’ death of ground-breaking artists like Michael Jackson,  Elvis Presley, or Hank Williams.   Even as a physician, I began to wonder a number of questions.  Do great music artists die young?  Are there certain conditions that are more likely to cause a star’s demise?  And finally, is there some lesson to be learned that might help our remaining beloved music artists?

music artists die young
Prince in 2008. Photo curtesy of Micahmedia at en.wikipedia

I began by tabulating the vital statistics on the 252 members of Rolling Stone Magazine’s “100 Greatest Artists” from the music industry. The list ranged from the #1 group The Beatles with two members that met a premature death (John Lennon at age 40 and George Harrison at age 58) to the #100 group The Talking Heads without a death amongst them.  In between, were stars like Jimi Hendricks who died at age 27 from a drug overdose, Bob Marley who passed at 36 from skin cancer, and Marvin Gaye who was shot and killed by his father at age 44.  In all, 82 of the 252 members of this elite group had died.

Homicides and Accidental Deaths

music artists die young
Sam Cooke in 1961

There were six homicides for various reasons ranging from a psychiatric obsession that lead to the shooting of John Lennon, to the planned ‘hits’ on rappers Tupac Shakur and Jam Master Jay.  There is still a good deal of controversy surrounding the shooting of Sam Cooke by a female hotel manager who was likely protecting a prostitute who had robbed him.  Al Jackson Jr., the renowned drummer with Booker T & the MGs, was shot 5 times in the back by a burglar in his home amongst mysterious circumstances that still baffle authorities.

An accident can happen to anyone, but the “100 Greatest ” have more than their share. There were numerous accidental overdoses including  Sid Vicious of the Sex Pistols at age 21, David Ruffin of the Temptations at age 50, Rudy Lewis at age 27 of The Drifters, and country great Gram Parsons who was found dead at age 26.

While your odds of dying in a plane crash are about 1 in 5 million, if you are one of the “100 Greatest” those odds jump to 1 in 84.  Buddy Holly, Otis Redding, and Ronnie Van Zant of the Lynyrd Skynyrd Band all died in airplane accidents while on tour.

Increased Liver Disease

music artists die young
The Doors
By Elektra Records-Joel Brodsky

While liver-related diseases make up only 1.4% of the general population’s cause of death, it comprised over three times that number among the “100 Greatest Artists” deaths.  The increased occurrence of these diseases is probably related to the elevated alcohol and drug use in this group. Liver bile duct cancers that are normally extremely rare in the general population ran suspiciously high in our small but esteemed group with Ray Manzarek of The Doors and Tommy Ramone of the Ramones both dying prematurely from a condition that normally effects less than one in a thousand .

Tobacco Use Effects

music artists die young
Eddie Kendricks of the Temptations

The vast majority of the “Great 100” were born in the 1940’s and reached maturity during the 1960’s when tobacco smoking peaked.  As a result, an increased number of artists died from lung cancer including George Harrison age 58 of the Beatles, Carl Wilson of the Beachboys at age 51, Richard White of Pink Floyd at age 65, Eddie Kendricks of the Temptations at age 52, and Obie Benson of the Four Tops at age 69.  Throat cancer, also linked with smoking, caused the deaths of country great Carl Perkins at 65 and Levon Helm of The Band at 71.

A good number of the “100 Greatest” had heart attacks or heart failure  and included Ian Stewart age 47 of the Rolling Stones, blues greats Muddy Waters age 70, Howlin Wolf age 65, Roy Orbison age 52,  and Jackie Wilson at age 49.

We recently saw Glenn Frey succumb to pneumonia, but so did Jackie Wilson at age 49, nine years after a having a massive heart attack.  James Brown complained of a persistent cough and declining health before he passed at age 73 with the cause listed as congestive heart failure as a result of pneumonia.

Among those dead, the average age was 49.

One of the two shocking outcomes deals with life expectancy. While the average American male has a life expectancy of about 75 years, the males in the “100 Greatest Artists” who have died had an average age of just over 49 years and makes up almost one third of the entire group. Factoring their birth year and a life expectancy of 75 years, only 44  should have died by now, instead of the 82.  Incidentally, of the 44 that should have died based on life expectancy, 19 are still alive.

Alcohol and drug abuse

Dr Greg Hall
Click LINK to read more about alcohol abuse.

The second shocking outcome was the sobering and disproportional occurrence of alcohol and drug-related deaths ranging from Kurt Cobain’s gunshot suicide while intoxicated to Duane Allman of the Allman Brothers accidental death on a motorcycle while impaired. Members of legendary bands like The Who (John Entwistle age 57 and Keith Moon age 32), The Doors (Jim Morrison age 27), The Byrds (Gene Clark age 46 and Micheal Clarke age 47), The Band (Rick Danko age 55 and Richard Manuel age 42), and others all succumbing to alcohol or drug-induced death.

There were many including The Grateful Dead’s Jerry Garcia and country star Hank Williams who declined more slowly over the years from substance abuse while their organs deteriorated, and the official cause of death was heart-related, but in reality the cause may have been more directly related to substance abuse.

Alcohol and drugs accounted for at least one in ten deaths of these great artists, while nationally substance abuse as a cause of death effects one in 33. The threefold difference points to the much greater access and use of drugs and alcohol among these ultra-talented artists.

 

Too Much Opioid Use & Abuse

Dr Greg HallCurrently, the US is in the midst of a opioid abuse epidemic with heroin and prescription drug overdoses setting records across the country. Elvis Presley, Jimi Hendrix, Janis Joplin, Sid Vicious, Gram Parsons, Whitney Houston (who didn’t make this 100 Greatest List), Michael Jackson, and now possibly Prince all dying from accidental opioid overdose. While it is still unclear what the cause of death will be in Prince’s case, early evidence points toward opioids.

Controlling  the effects of oxycodone, fentanyl, heroin or morphine and thereby reducing accidental death is difficult, and for these stars and countless others across the world, in the end . . . impossible.  Put another way, without the inappropriate use of opioids or their addiction, all of these stars could still be alive.

What music could those who died young have created if they were given the chance to live and flourish? And more importantly for us, who’s next?

Laser Tattoo Removal on Dark Skin

Dark skin present some problems

As you have probably heard, laser tattoo removal on dark skin is a real challenge.  The process takes longer, is frequently more expensive (because you have to go more often), and can be more plagued by less perfect outcomes. The modern lasers that are used work best when there is a significant contrast between the ink color and the skin color.  By definition, “colored skin” with an ink color on top represents less contrast.  In short, there is less “difference.”  The less difference presents a challenge for the laser.

Because African Americans have a “keloid” skin reaction much more easily than white Americans, a tattoo treatment laser result can (and frequently does) show this ‘build-up’ of skin.  A keloid is a build-up of scar tissue that frequently doesn’t go away. In the picture shown, the keloids are on his biceps.

Laser Tattoo Removal on Dark SkinIn deciding whether to have laser tattoo treatments, you will have to decide if you would be “okay” with a scarred outcome rather than a tattoo.  The current lasers on the market are not ideal for darker skin colors and the outcomes are frequently not what people expected.

The key is to treat skin of color differently than white skin. Not better or worse, simply different.  In these cases, laser tattoo removal on dark skin has to be approached delicately and with great care.  Slow and steady is always the best approach and wait 6 weeks at least between sessions to allow your skin to heal.

The laser technician should generally use a lower setting (or lower power level) initially to see how your particular skin turns out.  If significant scarring occurs, use adjust appropriately.  Many scars that initially occur after a laser treatment, will fade with time . . as all scars do.  Allow that healing to occur between sessions.

Once people finally decide to try to remove a tattoo, they are usually in a hurry and want to rush the process, but “slow and steady” always wins the race. And doing proper research is the key.  Take your time, choose and laser treatment facility that is used to skin of color, and wait a little extra time between treatments.

Genetic Clues Are Ignored By Too Many Doctors

Genetic Clues Ignored

With the availability of home genetic testing kits from companies such as “23andMe” and “Ancestry DNA,” more people will be getting information about their genetic lineage and what races and ethnicities of the world are included in their DNA. Geneticists, meanwhile, are also getting more tailored information about disease risk and prevalence as genetic testing in medical research centers continues. Physicians accept that cystic fibrosis, for example, is much more common in people with Northern European ancestry and that sickle cell disease occurs dramatically more often in people with African origins. These commonly accepted racial and ethnic differences in disease prevalence are just the tip of the iceberg when looking at clinical differences that vary based on genetics. But there’s a problem, a recent study from the National Institutes of Health found. Many physicians and other providers are uncomfortable discussing race with their patients, and also reticent to connect race or ethnicity to genetics and clinical decision-making, the study suggested. Overall, physician focus groups “asserted that genetics has a limited role in explaining racial differences in health,” the authors added. As a primary care physician who teaches urban health to medical students and as a state minority health commissioner who advocates for health equity, I see this as a problem that health care systems, and their providers, need to address.

The state of the science

Commercial DNA tests, such as those provided by 23andMe, not only give people their racial and ethnic lineage but also can provide a weighted risk for diabetes, stomach ulcers, cancer and many other diseases. In April, the FDA granted approval to 23andMe to sell reports to consumers that tell them whether they may be at heightened risk. These companies already have the data that describe the risks for health problems based on the percentage of their ancestry composition. Those differences have been published and known in academic circles for many years. With the widespread availability of DNA tests, patients will now know their increased individual risks. For example, Ashkenazi Jews, a specific Jewish ethnic population originating from Central and Eastern Europe, are known for having a disproportionate occurrence of a number of diseases, including Tay-Sachs disease, amyloidosis, breast cancer, colon cancer and many more. The BRCA1/2 gene mutation greatly increases the propensity for breast and colon cancer and occurs in 1 in 40 people of Ashkenazi Jewish heritage, whereas 1 in 800 Americans in general carry that mutation. This 20-fold increased risk should prompt more aggressive screening for the gene, and more frequent and earlier mammography and colonoscopies in Ashkenazi Jews compared to the general population. Relatively higher rates of these cancers occur in certain populations, such as Ashkenazi Jews, and demonstrates the need for more nuanced care based on data that is already available. But this information is too infrequently accessed by providers.

Genetics knowledge growing fast

African-Americans are another group with higher rates of certain genetically driven diseases. African-American men have an increased occurrence of prostate cancer, kidney failure, stroke and other health problems. Prostate cancer in African-American men, for example, grows faster and metastasizes four times as often than in European-Americans.
African-American men are at higher risk for prostate cancer. pixelmedia/From www.shutterstock.com
But despite this increased risk for prostate cancer, doctors’ use of the PSA (prostate specific antigen), a test that works well with identifying prostate cancer in African-Americans, has steadily decreased due to recommendations aimed at majority patients who come from European-related heritage. In European-Americans, prostate cancer can be more indolent and occurs at a lower rate than African-Americans. Also, certain types of blood pressure medications – ACE inhibitors, for example – lead to worse outcomes in African-Americans when used singularly as first-line therapy for high blood pressure, yet these medications work very well in Americans of European decent, a large study of hypertension therapy found. A follow-up study that looked at subsequent clinical practices – which was done in response to changed recommendations based on race – showed nearly a third of African-American hypertensive patients continued to be prescribed medications that cause worse outcomes. African-Americans also have a four-fold increased risk for renal disease leading to dialysis. Geneticists suspect that they have identified the gene that drives this difference yet most clinicians do not have the resources to test for this gene and identify the 30 percent of African-Americans that carry it. And a gene that greatly increases the risk for Alzheimer’s disease, APOE-4, has also been identified and occurs disproportionately higher in European-Americans yet is almost nonexistent in African-Americans and is inconsistent in Hispanic-Americans. Great controversy exists surrounding the testing for this gene, given the devastating impact it could have on a patient or family. (Hispanic and African-Americans still have a very significant risk for Alzheimer’s disease, but it is not driven by this gene).

Genetically different responses to medications

Patient response to medications vary according to the presence or absence of genetic variants, which can impact the dose and the effect of many pharmaceuticals. Some of these differences can be anticipated based on race or ethnicity. For example, Warfarin is a commonly used medication in the treatment of a number of cardiovascular disorders including atrial fibrillation, deep vein thrombosis and heart valve replacement. It shows wide variations in dosing, with Americans of Asian descent requiring less medication and African-Americans requiring more to achieve equal effects. European-Americans have a variant gene that make having a major bleed on Warfarin much higher.
Some types of medications affect different groups of people in different ways. Maoyunping/From www.shutterstock.com
A popular cholesterol-lowering medication, Rosuvastatin, better known as trade name Crestor, is twice as powerful in patients of Asian descent, and their manufacturing label indicates starting at a much lower dose in this population. In fact, the highest manufactured pill dose of Crestor is “contraindicated in Asian patients.”

Patient-centered care is the key

Because of the “patient-centered” movement in hospitals, clinics and insurance plans, providers are now feeling increased pressure to improve the quality of care provided to individual patients. Many outcomes and patient cost of care are now tracked by providers. And countless well-designed studies have validated verified differences in the clinical care of a number of pervasive diseases based on ancestry. Providers need to educate themselves about the important differences that exist in their patient populations. Health disparities, while driven by a number of social factors, are also the result of some clinicians not applying known nuances in the care of special populations. The ConversationAs home genetic testing grows, patients will be bringing their results to physicians for reaction and response. Physicians will need to be proactively prepared. Greg Hall, Assistant Clinical Professor, Case Western Reserve University This article was originally published on The Conversation. Read the original article.  

Smoking is an Addiction

Smoking isn't a habit, Smoking is an addiction.

As I encounter tobacco smokers in my practice, my family,  and in the community, one supreme issue comes through: smoking for these "hold-outs" despite smoke-free practices, taxes, and in-your-face campaigns is smoking is an addiction, and we need to start fully appreciating this problem more effectively in order to have an even greater impact. 
National campaigns have made great strides in decreasing the smoking rate over the last 50 years . . . from almost half of all Americans in 1965 to a new low of 15% in our most recent report. Unfortunately, that 15% still represents 47 million people, who still need help to stop. Smoking is an addictionThink about it . . . if someone said "let's take a leaf from a plant, dry it, wrap it up, set fire to it, and then inhale its smoke repeatedly" many would think the idea is crazy.  People who have never smoked struggle to understand because many still believe smoking is a 'habit' like spitting in public or chewing gun.  Many believe we can effect change by repeatedly saying "just say no" or by making logical associations between smoking and premature death.   While these approaches will (and have) worked with some, the many others who have continued to smoke in the face of these campaigns need better, more effective information that truly addresses why they don't stop.

Smoking Statistics

Unfortunately, a disproportional number of smokers come from underprivileged minorities. Consider these smoking numbers from the CDC's most recent data (2014): ·       More than 29 of every 100 American Indians/Alaska Natives (29.2%) ·       Nearly 28 of every 100 multiple race individuals (27.9%) ·       More than 18 of every 100 Whites (18.2%) ·       More than 17 of every 100 Blacks (17.5%) ·       About 11 of every 100 Hispanics (11.2%) ·       More than 9 of every 100 Asians (9.5%) And these numbers are after many heroic and largely successful campaigns.
What remains are still 70% of smokers who actively want to stop, and 40% who have actually tried in the last year. If smoking was truly a 'habit', most if not all of these people would have stopped already. 
What percentage of people who actually want to stop spitting in public, or stop chewing gum, are successful? I bet the number is in the high 90's. True 'habits' while aggravating to handle, aren't that hard to break. The body's addiction to nicotine is rapid and strong.

Smoking is an addictionFalse Beliefs

Unfortunately, many of the 47 million people who still smoke also believe smoking is a habit.  They actually believe they are 'choosing' to smoke.  Many think they 'want' to smoke.  But the evidence to the contrary is overwhelming. With economic strains, unemployment, low pay, and decreasing wages, why would someone choose to pay $8 for a pack of cigarettes (here in Cleveland, Ohio) which totals 40 cents per cigarette!  Based on the time to smoke a cigarette . . . 6 minutes, they pay 40 cents for 6 minutes of satisfaction.  People with financial hardships are not willingly choosing to spend that kind of money for a 'habit.' Add the overwhelming horrible health data associated with smoking which essentially says that whatever time a smoker spends smoking is lost on the back end. To put it differently, every minute spent smoking takes a minute off of your life. These are hard truths that almost everyone knows, but remains ignored by many.  To then call smoking a 'habit' in the face of all of these truths, is missing an overly obvious point.

The Cost of Tobacco Keeps Rising . . .

Many believed that raising the cost of cigarettes would simply 'price-out' its wide-spread use, and to a limited extend, it has, but unfortunately the hardened addicts will simply 'find' the money to buy 'what they need' at almost any cost.  Former Surgeon General C. Everett Koop, the first to assert that smoking was an addiction, initially faced strong opposition from the general public.  His mandate to place warning labels on the cigarette packs was revolutionary and one warning simply states: " Smoking causes a strong addiction, do not start it".
My overriding point to the smokers reading this article is to recognize the evidence staring you in the face.  Recognize that a "nicotine fit" is evidence  of withdrawal from an addictive substance.  Recognize that planning your day around smoking breaks, deciding your travel options based on smoking availability, and spending an outlandish amount of money on tobacco . . . are ALL signs of severe addiction.  
Smokers cannot take steps to address an addiction unless they first recognize its presence. The non-smokers (including many of my doctor colleagues) also need to stop having the smug "I'm not that stupid to smoke" and "why don't you just stop" attitude about the smokers in their practice.  Physicians should understand pure difficulty involved in stopping smoking.  Addictions are not stupid, they are real, strong, difficult to overcome, and need to be addressed in a sensitive and effective way. Patients need a physician they trust to work with them to overcome this huge health problem.

Smoking is an addiction

Addiction is merely a diagnosis to be addressed.  It is not a sign of personality weakness or inferiority. Like high blood pressure, strokes, lactose intolerance, and the flu, addictions need to be treated with the proper approach. Let's start recognizing and treating nicotine addiction with proven and multi-pronged approaches. And let's take the taxes we collect from current tobacco users and help them stop.

DNR Code Status Explained

One of the more difficult tasks in your life is deciding a “DNR code status” for yourself or, worse yet, a loved one.  DNR is short for Do Not Resuscitate which basically means ‘do not attempt to bring me back to life’.  Some people feel very strongly about having peace at the end of life . . . that you pass this life without disturbance.  Others want to live at all cost and even if their heart is “bad”, give them every chance to live. These two philosophical differences represent the two ends of a spectrum.  If you’ve lived a long life, get ill, and decline in health, your passing is expected . . . and to perform CPR (chest compressions or shocks) seems cruel to some as your last moments could be painful. 

In Ohio, the code status is limited to three: Full Code, DNR Comfort Care Arrest, and DNR Comfort Care.

The naming of these three advanced directives is helpful in some ways and confusing in others. DNR Code Status designations vary from state to state or even from county to county so find out what applies specifically in your area.

In Ohio (where my patients are located), what follows below is what applies to you.

We’ll review these code status’ individually and then go over some examples so you can be perfectly clear on the implications.

FULL CODE

Full code is easy to describe. It means you want “everything” that is medically possible done to keep you (or your loved one) alive. . . no matter what. This essentially means that no matter how much suffering is involved while getting care, it is worth it to get better when all is said and done.

When patients are diagnosed with cancer, many undergo chemotherapy that may cause nausea, vomiting, weight loss, hair loss, diarrhea, and more. . . all in order to get rid of the cancer, and recover and lead a happy normal life after the dust settles. If your heart stopped during this time, it would be appropriate to shock (with the paddles and the doctor yells “CLEAR” and then ZAP) the patient in an attempt to re-start the heart and get them past this sick time. 

You get everything that is clinically indicated.

Not everything that is medically possible. Your doctor still has the last say what is medically reasonable. 

DNR Comfort Care Arrest

This DNR code status is the confusing one! DNR Comfort Care Arrest essentially means that the patient is a FULL CODE until they “arrest” (heart stops or they stop breathing) at which point they would be made “comfortable” without shocking the heart or being put on a ventilator. This DNR code status is appropriate for most ‘older people’ or patients with heart or lung disease.

If you are 85 years old and your heart stops, it is because your heart has run its course. No amount of shocking and chest compressions will convince your heart to start again.  Attempts to start your heart will be futile, and your last moments will be painful as electric shocks and other interventions hurt (again, we tolerate the pain of these options with a FULL CODE so that we can live in case the heart stops and its not because it has run its course).

DNR Comfort Care Arrest is appropriate for most older patients because they will get everything clinically available to them, but when their last moment comes (if they “arrest”), they will be be “kept comfortable”.

With a DNR Comfort Care Arrest, you will get:

  • Surgery if needed
  • Antibiotics for all infections indicated
  • Intensive care treatment (ICU, etc.)
  • Chemotherapy for cancers
  • Anything else medically indicated

DNR Comfort Care

This DNR code status designation means that comfort will be the primary concern at all times. Comfort will drive all medical decisions.

DNR Comfort Care does NOT mean you get NO CARE. 

DNR Comfort Care means that the care you receive will be tailored with your comfort and happiness in mind.  It stresses the quality of your life, not the quantity. Three happy pain free days would be better than ten painful stressful days when both result in death in the end.

Hospice patients typically have a DNR Comfort Care code status. 

DNR Comfort Care CardBecause this can be confusing, here are some examples:

  • Urinary tract infection: could be treated because it is uncomfortable to have one
  • Chemotherapy for cancer treatment would not be offered unless there were specifically causing pain (that was best treated in this way).
  • A patient would not be sent to the hospital unless they would be more comfortable there.  Being packed up in an ambulance, put in the cold, sat in an emergency room, then transported to a hospital bed, then IV’s placed in arms, etc. is NOT comfortable. This situation is to be avoided if comfort is a prime directive.
  • Surgery will usually NOT be done.

Sometimes people carry a identification card for caregivers to see. HERE is one provided by the state.

This summary was difficult to put together (I admit), therefore there may be different angles, approaches to discussion, philosophical views, etc. that I left out. The important point is to have a honest conversation with a doctor you trust. Everything else will flow from there . . .

 

Please add your take on this in the comment section below, and I am sure this explanation will improve with more input!!!

 

Cleveland Black Doctor

Cleveland Black Doctor Cleveland Black Doctor

If you are looking for a Cleveland Black doctor or physician, look no further . . . Dr. Gregory L. Hall is the premier choice in Northeast Ohio. As a specialist in Internal Medicine, he sees patients age 18 and up. While many practices make you wait weeks to see the doctor, we’ll see you quickly, most of the time within the week.

African Americans have particularly severe problems with hypertension, strokes, obesity, and heart disease . . . and also have slightly different needs in the clinical care of these disorders.  Having the expertise and cultural competence in the care of African Americans is Dr. Hall’s specialty, and he is currently writing a book on the special needs of this population.

Louis Stokes Jeff Johnson
From Left to right, Jeff Johnson, Louis Stokes, & Greg Hall, MD

Born and raised in Cleveland’s Glenville neighborhood, Dr. Hall is very familiar with the medical resources available in Northeast Ohio and refers to specialists in their field from across the region.

He also understands the issues specific to the African American Community and makes an extra effort to diagnose and treat these conditions before they can cause harm.

Cleveland Black Doctor Dr. Hall’s office is conveniently located at 464 Richmond Road at the corner of Richmond and Highland in Richmond Hts, Ohio.

Trained at the world famous Cleveland Clinic, Dr. Hall provides up-to-date medical care in a family-like environment. Caring and comical, you will feel immediately at home with Dr. Hall and his staff. If you want a Cleveland-born Black doctor who make you feel at ease and takes time with you, look no further.

Most insurances are excepted, and we provide a sliding scale for uninsured patients who qualify.

Call the office of Gregory L. Hall, MD for an appointment, and you can be seen as soon as the next few days.

216 881-5055

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Cleveland African American Physician

Cleveland African American PhysicianIf you are looking for a Cleveland African American Physician, look no further . . . Dr. Gregory L. Hall is the premier choice in Northeast Ohio. As a specialist in Internal Medicine, he sees patients age 18 and up.  We’ll see you quickly, most of the time within the week.

Internal Medicine is a primary care specialty for adults and Dr. Hall sees patients with diabetes, high blood pressure, arthritis, headaches, dementia, and much more. He will be on your side . . . and has a special ability to explain complicated diseases and conditions.

African Americans have particularly severe problems with hypertension, strokes, obesity, and heart disease . . . and also have slightly different needs in the clinical care of these disorders.  Having the expertise and cultural competence in the care of African Americans is Dr. Hall’s specialty, and he is currently writing a book on the special needs of this population.

Born and raised in Cleveland’s Glenville neighborhood, Dr. Hall is very familiar with the medical resources available in Northeast Ohio and refers to specialists in their field from across the region.

Cleveland African American PhysicianHe also understands the issues specific to the African American Community and makes an extra effort to establish trust, and diagnose and treat these conditions before they can cause harm.

Dr. Hall’s sees patients at his office at 464 Richmond Road at the corner of Richmond and Highland Road in Richmond Heights, Ohio.

Trained at the world famous Cleveland Clinic, Dr. Hall provides up-to-date medical care in a family-like environment. Caring and comical, you will feel immediately at home with Dr. Hall and his staff.

Most insurances are excepted, and we provide a sliding scale for uninsured patients who qualify.

Call the office of Gregory L. Hall, MD for an appointment, and we will see you real soon.

216 881-5055

 

 

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Medicare Annual Preventive Health Exam

If you are 65 years or older, you are entitled to a Medicare annual preventive health exam that is covered at no additional cost.  During this visit, we will review your social and medical history including family risks, tobacco and drug use, your diet and physical activities, current medications and nutritional supplements, as well as any hospital stays or surgeries.

Annual Preventative ExamWe will also review if you have any risk factors for depression or other mood problems.

The overall purpose of a routine preventive exam is to identify potential health problems in the early stages when they may be easier to treat.

This exam is prevention focused, not problem focused. If you have a new health problem or other diagnoses that need to be addressed during your preventive office visit (high blood pressure, diabetes, skin rash, or headaches) we may bill part of the exam at 100 percent for your annual preventive exam, and part of your office visit for treatment of your diagnosis. The portion of your visit related to the treatment of your diagnosis would apply toward your deductible and coinsurance. If we feel that the majority of the time was spent with medical concerns, the entire visit may be considered a medical treatment visit and would not be billed as preventive and we will schedule another visit as preventative. 

At our preventative visit, we will also review appropriate screening tests that need to be scheduled including:

  • ColonoscopyColonoscopy: a screening test that looks for pre-cancerous cells in your intestine.
  • Mammography: an x-ray test that looks for early breast cancers
  • Bone Density Study: an x-ray test that checks the strength of your bones
  • Prostate Specific Antigen: a blood test that estimates your risk for prostate cancer.
  • Ultrasound Screening for Abdominal Aortic Aneurysm
  • Screening for dementia, depression, alcoholism
  • Human Immunodeficiency Virus (HIV) Screening
  • Cardiovascular Disease Screening Blood Tests

We may also discuss “Advanced Directives.”  This is where we talk about your wishes as it relates to end of life care. Obviously, this talk is best done when you are NOT at the end of your life, and any decisions you make are not binding . . . in other words you can always change your mind or put off making a decision.  It is always good to know your options.

GLH Walking in exam roomThe annual preventive health exam is a great time to clarify any questions about prevention, screening, advanced directives and more.

Ask questions and get answers!

 

 

Links

Medicare Resources

Medicare Benefit

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Sees Jehovah’s Witness Patients

Treats Jehovah's Witness Patients

Doctor Treats Jehovah’s Witness Patients

Dr. Greg Hall treats Jehovah’s Witness patients for a variety of disorders for over the last 20 years. While treating many families, Dr. Hall understands and respects Jehovah Witnesses’ beliefs as it relates to blood product use, and will vehemently defend their wishes to avoid blood and blood products, while exploring all of the many options that are available instead of transfusions. 

Other than avoiding transfusions, Jehovah’s Witnesses want and expect the best medical care with the latest clinical interventions available.

“Cleveland and Northeast Ohio Jehovah Witnesses are a great diverse community of friends, and I am honored that so many are my loyal patients.”

Jehovah’s Witnesses expect the same high clinical standards as any other religion, their only expectation is the exclusion of blood product use. With modern medicine and incredible advances, the avoidance of blood products does not complicate the healing process in any way. And with blood borne infections as they are, the risk – benefit of any one transfusion can easily be debated.

Knowing a patient’s wishes in advance allows sufficient time for planning and proper clinical management in any case.  The national drive toward “patient-centered care” stresses putting the patient, and their wishes and preferences, at the center of  the medical decision-making process.

“Avoidance of blood does not tie a physicians hands any more than the physician allows.”  

Greg Hall, MD

Sees Jehovah’s Witness PatientsJehovah’s Witnesses and blood avoidance . . . WHY?

This is a religious issue and NOT a medical or clinical issue. Both the Old and New Testaments have references to “abstain from blood.” (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29) Historically (and in the bible), blood has repeatedly been seen as “representing life.” (Leviticus 17:14) Jehovah’s Witnesses avoid taking blood not only in obedience to God, but also out of respect for him as the Giver of life.

For more information, CLICK HERE

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