15-51 Segment 1: It’s No Holiday In The ER

 

Synopsis: The holidays are like no other time in your local hospital’s emergency department. Having family in from out of town results in pickup football injuries, carving knife gashes, and maladies that should have been addressed long ago. Heart attacks additionally create a spike in dead-on-arrival cases greater than any other days of the year. Experts discuss why these occur and how to prevent them.

Host: Reed Pence. Guests: Dr. Christopher Michos, Connecticut ER physician; Dr. Robert Kloner, Director of Research, Heart Institute, Good Samaritan Hospital, Los Angeles and Professor of Medicine, Keck School of Medicine, University of Southern California; Dr. David Phillips, Professor of Sociology, University of California at San Diego.

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Christmas in the ER

Reed Pence: The Christmas and New Year’s holidays turn life upside down for many of us. And for the most part, that’s a good thing. We have a day or two off of work and the kids are out of school. Maybe relatives from out of town are staying in the spare bedroom. And there’s enough food in the refrigerator to feed an army, just waiting to be prepared. But when families gather over the holidays and we’re out of our routines, we can also get into trouble. Then it becomes the job of your local hospital emergency department.

Dr. Christopher Michos: What pretty much happens on those kinds of holidays like Christmas and New Year’s is sports related injuries when people decide to have that annual pickup game of basketball or football outside. It’s a weekend Warrior thing, so they develop sprains and strains of muscles, or broken bones.

Pence: Dr. Christopher Michos is a longtime emergency physician in Connecticut.

Michos: another one of the common injuries is when families gather around that Christmas table and they decide to slice up the turkey or ham, and they get those injuries where you’re using the electric carving knife or just the regular steel blade, and they get a little clumsy, or little bit careless in trying to slice up that holiday dinner and then people sustain the lacerations and thee cuts that usually require some surgical repair in the ER.

Pence: As you might expect, the pattern is a little different a week later.

Michos: Naturally when you talk about New Year’s. That’s when people unfortunately do stupid things, like party too much, drink too much, get themselves involved in unfortunate car accidents, or the next morning when they come in badly dehydrated and hung over and need medication to help overcome that constant vomiting and that dehydration and get some fluids in them.

Pence: During the holidays — especially after Christmas dinner — Michos also sees an influx of out-of-towners who should have been to see their local doctors long ago.

Michos: You get the large family get together and there’s always a conversation at the dinner table. “How have you been? What’s new? How’s your health been?” The common discussion about, “oh, I’ve been having chest pain,” or “I’ve been having a chronic cough, or a cough for a long period of time.” There’s that family concern about, “Oh my gosh, it sounds serious. You should get that checked out,” or, “Remember Aunt Martha had that and look what happened to her.” So that conversation prompts people to suddenly wake up and say, “Well, maybe I should get that checked out.” So that immediately prompts a trip to the emergency room.

Pence: the patient showing up may live hundreds of miles away and have a condition that could have been easily treated months ago. But Michos credits families for giving a push to get treatment at all.

Michos: It’s not the best place to go. A lot of these people are visiting from out of town, so they’re going to an unfamiliar area. We’re not able to get in touch with their private physician that’s been following them, or have access to their medical record. Maybe a cardiogram that they’ve had at another hospital or a private doctor’s office, a complete list of their medications. I think people put it off because of fear. It’s very natural. A lot of complaints are not serious. The emergency department is not necessarily the best place to have these things checked out that have been going on for a long time. But people put thermo off because of fear and then all of a sudden they have the family confronting that, they’re bringing stories about other family members that have had more serious problems that went unchecked for a long time, and then they say, “Okay” and to appease the family they’ll come in to the emergency department.

Pence: Most of those are not life-or-death situations. But it turns out that the ones that are also increase during the winter. When cold weather comes, deaths increase. And Michos says snow is often to blame.

Michos: People decide to go outside and shovel when they shouldn’t. Certainly that puts a tremendous stress on the heart, the physical activity and also the cold weather really is what brings in most people for the condition of heart attacks.

Pence: However, the wintertime increase in deaths doesn’t happen just in snowy New England or in the frozen tundra of the Dakotas. Studies show the same thing is repeated in Florida, Arizona and California where it doesn’t snow at all.

Dr. Robert Cloner: We actually did a study with Los Angeles County looking at death rates, averaged over a course of twelve years. We were surprised to see that death rates were highest during the winter months in Los Angeles, specifically December-January, where the cardiac death rates, death due to heart disease, was about 33% increased over deaths during the summer and fall.

Pence: Dr. Robert Cloner is director of research at the Heart Institute at Good Samaritan Hospital in Los Angeles and professor of medicine at the University of Southern California’s Keck School of Medicine. Kloner says that deaths start to rise right around Thanksgiving, and doctors don’t really know why. He says it’s possible that small changes in temperature can make a big difference.

Kloner: Now there are changes in the climate here in Los Angeles. It is cooler during the winter, but it’s not that much cooler during the winter than other times of year. Bu there is changes in temperature that occur, so it is colder during those months as well. We thought that that might explain the phenomenon because it’s known that during the cold there are changes in physiology, so that blood vessels tend to be more clamped down during the cold, blood clots tend to occur easier during the cold, and people might exert more energy during the cold especially in you’re living in a climate that has snow, but we don’t have to much snow here except in the mountains.

Pence: But it’s not just the general wintertime increase in deaths that has doctors scratching their heads. It’s those few particular days when sudden death rates are worst. Every year, almost without fail.

Dr. David Phillips: December 25, December 26 and January 1 have more dead on arrival deaths, more emergency department deaths than on any other day of the year.  

Pence: Dr. David Phillips is professor of sociology at the University of California at San Diego.

Phillips: Above and beyond the normal winter increase, there are these separate spikes in deaths for Christmas and New Year’s, above and beyond the normal increase. If you look at the graph of mortality for cardiac deaths and non-cardiac deaths, you’ll see that there’s a kind of hill in the middle where winter occurs, but on top of that hill there are two antennae – one for Christmas and one for New Year.

Pence: The spike in deaths during the holidays was originally dubbed “the Merry Christmas Coronary” thanks to Kloner’s pioneering work documenting cardiac events. But since then, Phillips has published studies in the journals Circulation and Social Science and Medicine, showing that it’s not only heart attacks and strokes that spike when we’re opening Christmas presents or watching the Rose Bowl on TV.

Phillips: Everything is up. It’s amazing. Take the most common kinds of natural causes of death, they are all spiking in the dead on arrival and ED, emergency department categories. They’re all spiking on Christmas and on New Year.      

Pence: One factor that could explain the spike in emergency room deaths is that a trip to the hospital is simply an inconvenience at Christmas dinner, so a life that could ordinarily be saved gets help too late.

Kloner: People sometimes delay seeking medical attention during the holidays. In other words, “I’ll wait until after the holidays are over.” And that might be dangerous. In other words, if you put off seeing someone for the chest pain you’re getting at a family dinner, or something like that, you say, “Oh, I’ll wait until after the dinner,” or “I’ll wait until after the holidays,” that delay in seeking medical help could possibly contribute to this phenomenon of increased cardiac deaths around the holidays.

Phillips: Another possible explanation that has not been ruled out by the data is that the number of medical personnel goes down around the holidays because they want to take holidays, too. In addition to that, it’s probable that the medical personnel who are remaining to serve patients on Christmas and New Year are more likely to be junior because the senior ones have pulled rank and said, “I’m taking a vacation now.”      

Pence: But why would people be having more critical health problems in the first place right around the holidays? Doctors have a whole catalog of possible causes, but no explanation for everything.

Phillips: Well it can’t be just “winteriness,” because this increase is above and beyond the normal increase in winter, and actually the increase is smaller in the northern states than in the southern states. You’d expect that if it was just winter the effect would be bigger in the northern states. It’s unlikely to be psychological stress induced by the holiday because nobody has demonstrated that psychological stress can produce a sharp sudden spike in deaths from pretty near every major cause on Christmas, and then a separate spike on New Year. You might possibly get a spike from this cause of death or that cause of death from psychological stress, but it’s unlikely that you would get one from cancer and other causes of death also.

Pence: The flu may also be a factor. Kloner says there’s evidence that people who get a flu shot have lower rates of cardiac events. But he also believes that stress remains a pretty good candidate. Some people can relax during the holidays, but many others find them anything but restful.

Kloner: They can be stressful. Sometimes you’re facing family members you not have seen for a while. People expect you to purchase presents, so there’s a financial burden. If you’re like me I hate shopping, [laughter] going to the mall and find parking and running around the mall to me is not something that’s a lot of fun.”

Pence: Then we top off our stress with some of the most unhealthy eating of the year.

Kloner: We know that there’s a tendency to take in more salty foods during the holidays. Salt can lead to increase in water retention, which can be bad for our heart failure patients. We also know that excess alcohol can have some negative effects on the heart, including inducing arrhythmias, which is altered heart beats, one is called atrial fibrillation, which sometimes occurs with excess alcohol intake, that’s often called “holiday heart syndrome. There are also situations where the excess alcohol can suppress the strength of the heartbeat and make the heart somewhat weaker. So alcohol in moderation has been associated in some studies with a reduction in cardiac events, but unfortunately, people aren’t always moderate during the holiday season.

Pence: So what does this all mean as we approach the holidays? First, Kloner says don’t let the holidays keep you from taking your medications. Then, take a few precautions like getting a flu shot.

Kloner: I think the other is to consider moderation in consuming alcohol, fat, salt. This is especially true in patients of known heart disease. Also, if you have known heart disease, exposure to severe cold should be either avoided or make sure you are bundled up because severe cold can cause vasoconstriction, making the blood vessels clamp down in both the heart and other parts of the body. This can decrease the supply of oxygen to the heart. If your blood vessels outside the heart are clamped down the heart has to work harder to pump through them, and increases the oxygen demand. We also know that certain activities during the cold, especially in cold climates, such as snow shoveling can be deleterious. Snow shoveling is an isometric exercise. A person with known heart disease or coronary disease, thatcan put extra stress on the heart.

Pence: Finally, Kloner says if there’s one person in your family who every year pushes your buttons and makes your blood boil, just keep your distance and don’t take the bait. Your heart — and your family — will thank you.  I’m Reed Pence.

 

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