UPDATE on EVALI(E-Cigarette and Vaping Associated Lung Injury)

 

UPDATE ON E-CIGARETTE AND VAPING RELATED LUNG INJURY: Vitamin E Acetate has been linked to e-cigarette and vaping lung injuries by the CDC investigation. This does NOT mean there are no other dangerous compounds present but this is certainly a breakthrough in furthering our understanding of EVALI. For now, we continue to advise our patients to avoid e-cigarettes and vaping products. Please talk to your cannabis physician about other options for ingestion of medical cannabis. #evali#vaping #cannabiscommunity #vapingcommunity #stayinformed #marijuana#marijuanacommunity @ Canna Therapy MD

Trouble sleeping? Cannabis could help

Night shift worker? Stress keeping you up? Can’t get your mind to stop racing at the end of the day? Did you know that not getting 7-8 hours of sleep a night can increase your risk of obesity, diabetes and cardiovascular disease? Studies show more than a third of Americans are not getting enough sleep. Cannabis can help you get the sleep that your body needs! #cannabis #cannabiscommunity #medicalcannabis#medicalmarijuana #insomnia #cantsleep #medicalcannabiscard#insomniac #cannabishelps

 

Schedule an appointment today to talk with Dr. Rad or Dr. Khalsa about any sleep troubles you are experiencing!

Visiting a cannabis clinic

Check out advice that Dr. Rad and Dr. Khalsa give on visiting a medical cannabis clinic!  This was published in MO Greenway Magazine, which can be found at the following link: https://mogreenway.com

 

VAPI: Vaping Associated Pulmonary Illness

Dr. Rad recently got a chance to speak with senior writer Katie Heaney for The Cut, New York Magazine about vaping related lung illness.

Check out the article here for great information about the recent developments and advice on how to prevent this from happening to you.

https://www.thecut.com/2019/09/are-weed-pens-as-dangerous-as-vaping-nicotine.html

For now, Canna Therapy MD feels all patients should avoid vaping and vaping related products for BOTH nicotine and THC until the CDC is able to complete their investigation into the underlying cause.

Please seek immediate emergency care and inform your emergency physician if you develop chest pain, shortness of breath, fever, abdominal pain, nausea, vomiting or diarrhea after vaping in the last 90 days.

The CDC also encourages patients to report their vaping related symptoms to: https://www.safetyreporting.hhs.gov/SRP2/en/Home.aspx?sid=a6939cbf-f782-4509-8544-0921663abefb

Dr. Rad: Why this ER doc advocates for medical cannabis

“24 year old female, found down. GCS 3, CPR in progress. ETA 5 min.”

The radio crackled off and I immediately started running towards the resuscitation bay to meet the EMS crew.

I methodically slid on the vibrant blue nitrile gloves, carefully placed my face shield on and prepared my intubation kit.

All codes are the same. The fundamentals of medicine kick in. Airway. Breathing. Circulation. A. B. C. In emergency medicine, we train to maintain composure in chaotic situations. I take a deep breath and prepare to take charge.

When EMS arrived, one crew member was performing chest compressions, sweat dripping down his face. The other crew members carefully transported her from their stretcher to our bed. The medic immediately briefed us, “No improvement, 1 round of Epi given, no shockable rhythm en route.”

“Ok everyone, continue chest compressions and administer the next round of Epi” I said.

Multiple rounds of chest compressions and medications were given. I placed an ultrasound over her chest during the pulse check. Her heart was still. The room was still. We all knew her fate.

“Time of death 1437.” I stripped off the face shield, removed the gloves and glanced at her family through the window.

Often times in the moment, emergency physicians are focused on the task at hand. What can I do to bring her pulse back? Is there a shockable rhythm? Is there a reversible cause for her death?

A lot of times, we can’t get them back, as hard as we might try. I once had an attending tell me, “They’re already dead. You can’t make them deader. Do your best to bring them back and be there for the people who are left behind.”

I walked over to the family and gave the speech I was used to giving over the years. I watched the color drain out of their faces; guttural moans filled the room with despair. The questions flooded of “Why her? Why this? Why now?”

I couldn’t answer those questions. As I covered her body with a bright clean white hospital sheet, I glanced at her arms. Scars from the needle sticks searching for a viable vein for the heroin. Evidence of the long battle she had been through.

Colleagues, friends and family have all questioned why Dr. Khalsa and I felt a need to advocate for medical cannabis. Anyone who has been affected by the opiate crisis has never asked us why we do it, they simply thank us.

When you have firsthand experience with the gruesome toll of opiates, it is easy to advocate for safer treatment options. Physicians agree at this point that opiates are not the answer. However, patients are left with no other alternatives. As physicians, we cannot simply ignore pain control or defer it to the next doctor to worry about.

We understand the hesitancy both in the medical community and general population. For many years, cannabis has been stigmatized with both physicians and patients abusing the system. In the medical community, cannabis physicians are sometimes viewed as lesser-trained doctors, who frequently did not become board-certified in a specialty. In other words, this was just a way to “make a quick buck.” Another barrier is that medical education certainly does not include a section on medical cannabis. Physicians have to go out of their way to gain additional training and expertise in this area.

Dr. Khalsa and I want to change this perception. We are board certified physicians in emergency medicine and still practice on a regular basis. After working for many years in Colorado, we saw the good and bad of cannabis legalization and we readily discuss these risks and benefits with our patients.

No medication is perfect and we encourage the medical community and our patients to always maintain a guarded perspective on any novel treatment. Just look at the drug commercials on TV that subtly try to list over fifty various life-threatening side effects. These are commonly followed by large lawsuit advertisements for the previously mentioned side effects. No medication is taken without risks and this includes medical cannabis.

Yet, medical cannabis does show promise. We continually review the most recent literature on cannabis. But, we also listen to our patients. A common theme that comes up is that patients enjoy having control over their own health. They appreciate having an active role in determining strains, dosing and frequency of this medication. With any chronic illness, control is something that disappears over time. They feel mainstream medicine only contributes to their lack of control and medical cannabis helps them regain some balance.

Patients tell us about how they were able to cut out opiates from their lives, how they head into their chemotherapy sessions without enduring weeks of nausea and vomiting, how they enjoy their lives again without having to worry about daily intractable seizures.  We listen to their success stories.

Medical cannabis is not the right choice for everyone, but we are here to start the discussion about whom it can help.

Radhika Ratnabalasuriar MD

My Body has a Mind of Its Own: Sarah’s Story

SOAP Note Diaries

“ER docs practicing in a cannabis world”

My Body has a Mind of Its Own: Sarah’s Story

 

Subjective:

As I walk into the room I try to focus completely on Sarah, a young woman who is presenting to the emergency room today for numbness and tingling.

She sits calmly, although I can tell she is nervous.  She periodically jitters around in her hospital bed, laughs nervously and apologizes for coming to the emergency department.

“I just didn’t know where else to go.  It seems no one can help me and I know something is wrong.”

To be honest, as an EM (emergency medicine) physician I don’t love the vague complaint of numbness and tingling.  In my experience the causes are vast and with limited time and resources in the emergency room it seems impossible at times to find a diagnosis.  But, I’m going to try my best for Sarah.  I know she wouldn’t be here if it were not a last resort.

I ask her what’s been going on and she immediately loses her calm demeanor and bursts into frantic tears.  “It’s just been so frustrating, I feel like I am going crazy and I am really scared”. She reveals to me that she has been plagued for months by random numbness and tingling in her arms and legs, and now even has a little bit of weakness in her left arm that comes and goes.  Sometimes she feels her vision is going blurry.  Other days, she has painful spasms that coarse throughout her back like electricity striking her every 5 minutes. She lowers her voice and sheepishly admits, “On top of all that, I noticed I don’t even have a sexual drive anymore with my husband.”

Many people, including doctors, including ourselves at times, may brush Sarah off.  “You’re just stressed.  You need more sleep.  It’s all in your head.”  I can tell she has heard all this before as she quickly assures me again that she “is not crazy.”  I stop her.  “I don’t think you’re crazy Sarah.  Let’s get some further testing and see if we can figure out what is going on.” She smiles timidly, relieved that someone is taking her seriously. She just wants an answer.

Sarah’s MRI ended up showing characteristics concerning for multiple sclerosis.  The diagnosis is certainly not always this simple, but we got lucky, if you can call it that.

I went back into the room to discuss this with her.  You could sense her internal struggle between relief that something was wrong and she wasn’t “crazy” versus accepting that she now has to live with this new disease process.

Patients who deal with MS have various symptoms and challenges they face on a daily basis and we see them in the ER for many of these. Neuropathic pain, muscle spasms, spasticity, depression, anxiety, and insomnia just to name a few.  It is difficult to see them keep coming back to the ER feeling hopeless about their quality of life.

Objective: We reviewed the literature to see how patients like Sarah could improve their quality of life with medical cannabis.

Interestingly, spasticity seen with MS is one of the few diagnoses that has significant evidence-based studies to support the use of cannabis in its treatment. This type of evidence is what the medical community considers a “good” study that they feel comfortable using to guide their practice.

Many of the studies that are done on cannabis are simple observational studies which do not meet this rigorous evidence-based criteria.

It seems cannabis can be used to treat a range of symptoms including spasticity, muscle spasms, issues with mood and cognition, bladder and bowel problems, neuropathy and insomnia.

Cannabis is a known powerful antioxidant and some researchers ask the question if this could help reduce oxidative damage and slow death of neurons.  This would translate to slowing the overall process of multiple sclerosis.

Unfortunately, at this time there just isn’t enough research to know if this is possible. However, we find it an interesting area of future research.

Assessment and Plan: Medical cannabis has been shown to help with spasticity in people with MS.

With the correct guidance it could also potentially help with a number of other challenges people face with MS.  Since research is limited, it is best to trial medical cannabis in very small doses first to see if there is a benefit to the patient.

It can take a bit of trial and error to achieve the correct combination of cannabis to obtain the desired effect.  We suggest having the guidance of a Cannabis trained physician to accomplish your treatment goals.

As always, you should discuss your plan to use medical Cannabis with your neurologist and other specialists to make sure you achieve optimal treatment.  We also want to ensure it does not interfere with any other ongoing treatment plans you may have for your MS.

We DO NOT currently recommend using cannabis to try and slow the progression of MS, but this is something to continue to watch going forward as more research is produced.

Final Impression:

Sarah walked out of the emergency department that day feeling more empowered than she had in the last few months.

She knows it’s a long road ahead, but she tells me at least she has hope now.  And hope is a pretty priceless emotion to keep when you’re battling chronic illness.

As she walked out of the room, I smiled and thought, “You got this Sarah.  And we have your back.”

Recommended Reading and resources:

“Cannabis Pharmacy; the practical guide to medical marijuana” 2017 edition. By Michael backs with foreward by Andrew Weil, MD. Jack D McCjue MD medical editor.

“Cannabinoids in multiple sclerosis (CAMS) study: safety and efficacy data for 12 months follow up”

J ZajicekH SandersD WrightP VickeryW IngramS ReillyA NunnL TeareP Fox, and A Thompson

J Neurol Neurosurg Psychiatry. 2005 Dec; 76(12): 1664–1669.

“Effect of dronabinol on progression in progressive multiple sclerosis (CUPID): a randomised, placebo-controlled trial.”

Zajicek J1Ball S2Wright D2Vickery J2Nunn A3Miller D4Cano MG2McManus D4Mallik S4Hobart J2CUPID investigator group.

Lancet Neurol. 2013 Sep;12(9):857-865. doi: 10.1016/S1474-4422(13)70159-5. Epub 2013 Jul 13.

The SOAP Note Diaries: Introduction

The SOAP Note Diaries: “ER docs in a cannabis world”

Introduction:

Dr. Khalsa and I were initially nervous to take the leap and start specializing in medical cannabis.  We knew some of our colleagues would look down on us.  However a part of us always knew we were supposed to advocate for this patient population.  People who could genuinely benefit from medical cannabis.

This blog became a way that Dr. Khalsa and I could share our stories with you from working in the emergency department.  We encounter so many different people who are battling severe diseases and we feel they deserve access to medical cannabis without stigmatization.

They deserve to be treated as patients who are seeking medications that work best for them.

They deserve to be treated not as drug addicts or uneducated people but as patients who are looking for a different approach to their treatment plans, when nothing else seems to be working.

These are their stories and we hope we can do them justice.

Our hope is for this blog to bring a new perspective to the table.  Thank you for keeping an open mind and for taking the time to read our stories.

What is a SOAP note?

A SOAP note is used by many physicians to document the patient’s encounter.  It is a shorter simplified note made up of 3 parts.

“Subjective” explains why the patient is there.  This part is told completely from the side of the patient.  Why are they here today?  What is bothering them?  What makes it better?  What makes it worse?

In our blog, this is where we tell the patient’s story.  All names are fictional and specific details about the case have been changed to protect the patient’s privacy.

“Objective” is the physician’s evaluation of the patient, including a physical exam. It states the facts of what they have observed with the patient and their clinical findings.

In our blog, this is where we review the literature on medical cannabis related to a specific disease process.  We talk about what the studies showed, any weaknesses in the literature and any future research that is pending.

“Assessment and Plan” is the part where a physician documents what he/she thinks the diagnosis may be and his/her plan for further evaluation or treatment.

In our blog, this is where we summarize our thoughts on the disease and the effectiveness of medical cannabis.  They are our “take home points.”

‘Final Impression” is where the physician documents his/her final diagnosis and thoughts.

In our blog, this is where we express our final thoughts about the patient and topic at hand.

We always cite recommended resources and additional reading materials on the subject matter at the end of each blog post.

Thanks for reading!

Drs. Khalsa and Ratnabalasuriar

Fighting Cancer: Ann’s Story

Subjective:

I remember her face as I was breaking the news. Fighting back tears in her eyes while tightly clutching her husband’s hand. He was gently sobbing into her arms with a deep love in his eyes evident to any stranger like me. Ann had come to the emergency department (ED) for a bruised shoulder that just wasn’t getting better. She left that day with her entire world changed forever.

As an emergency doctor we are trained to move from room to room with pristine efficiency. Labs ordered? Check. Pain medication? Check. Follow up on the CT scan? Check. Discharge room 9, run to the cardiac code in room 1, speak to the consultant for room 3, reduce the shoulder in room 7? Check. Check. Check. Check.

Our chaos is a world I wouldn’t wish on anyone. It’s messy at times, unforgiving, and doesn’t care if you’re tired, hungry or upset. Life in the ED continues on with or without you.

But then you meet a family like Ann’s. A loving, happy family. A simple bump on the shoulder. You figure it’s been a few weeks, why not get an X-­‐ray just to make sure the bone is ok?

When I saw Ann, I immediately knew something was wrong even though she appeared well. In our field we refer to it as “spidey sense.” Instead of the X ray, I said, “Why don’t we get a CT of your chest? My job is to think of the worse things that could be causing your pain. I’d like to make sure your heart and lungs are OK.” “Sure,” she said. “Why not? I haven’t had a decent check up in awhile.”

As I scrolled through the images, all I could see were huge white threatening masses. In her lungs. Around her ribs. In her spine. Cancer. My world stopped.

“Oh Ann. How am I going to tell you this?” I think as my phone rings endlessly and the ambulances continue to stream in. The ED keeps moving and all of a sudden I feel paralyzed.

Ann is one of many patients I have diagnosed with cancer in the emergency department. It’s a terrible part of the job and none of us truly know how we have affected someone’s life after that day.

We see cancer patients come in and out of the emergency department for infections, fatigue, low blood counts, and frequent nausea and vomiting related to the side effects of chemotherapy.

As I ordered medication after medication for cancer patients, I started to wonder if there was a better way.

Objective:

Review of the literature led us to understand how medical cannabis can be used to treat cancer related symptoms.

Some try to stretch the effects of cannabis by claiming it cures cancer. This is partially true. We have seen antitumor effects of cannabis. However, we have also seen proliferative effects (causing the cancer to grow more). There is certainly potential there, and we have read some promising preclinical studies regarding treatment in breast cancer and glioblastoma multiforme. Despite this, we do not know enough to make such strong claims that cancer can be cured solely by cannabis.

Yet, we do see strong evidence that suggests it can be a wonderful adjunct to conventional cancer therapy, especially in treatment of nausea and vomiting.

Assessment and Plan:

Medical cannabis can serve as an adjunct in traditional chemotherapy regimens. At this time, it seems most helpful to treat cancer-­‐related symptoms such as nausea and vomiting. It is sometimes helpful to treat cancer-­‐related lack of appetite, sleep, nerve and organ pain.

Involving your oncologist in your decision to use medical cannabis is of the utmost importance.

Your medical team should strive to listen to your needs and help guide you in your care.

Remember, no single isolated medication is ever likely to be the answer when it comes to cancer treatment. At this time, we do NOT recommend only using cannabis as treatment for cancer.

We do acknowledge promising preclinical studies and look forward to future research evaluating cannabis and its role in targeted chemotherapy.

Final Impression:

I still think of Ann and her family quite often. I wonder how they are living day to day. If she is doing the things she loves, spending time with the people that matter.

In a moment, you can change someone’s life forever. I hope our patients know their stories stay with us. We go home and grieve for them. We think of them as we lay next to our loved ones at night. We are pulling for all the “Anns” out there.

Signed,

Radhika Ratnabalasuriar MD & Hari Khalsa MD

Recommended Reading and Resources:

P.F Whiting, R.F. Wolff, S. Deshpande, M. Di Nisio, S. Duffy,A. V. Hernandez, J.C. Keurentjes, S. Lang, K. Misso, S. Ryder, S. Schmidlkofer, M Westwood, J. Kleijnen, “Cannabinoids for Medical Use: A Systematic Review and Meta-­‐Analysis.” JAMA 2015;313:2456-­‐73.

D.I. Abhrams, M. Guzmán, “Cannabis in Cancer Care,” Clinical Pharmacology & Therapeutics 2015;313:2456-­‐73.

F.C. Rocha, J.G. Dos Santos Junior, S.C. Stefano, D.X. da Silveira, “Systemic Review of the Literature on Clinical and Experimental Trials on the Antitumor Effects of Cannabinoids in Gliomas,” Journal of Neuro-­‐Oncology 2014; 111:11-­‐24.

M.M. Caffarel, C. Andradas, E. Perez-­‐Gómez, M. Guzmán, C. Sanchez, “Cannabinoids: A New Hope for Breast Cancer Therapy?” Cancer Treatment Reviews. 2012;38:911-­‐8.