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Scot: All right. We're starting it over. I hit Record.

Dr. Chan: Rookie mistake. Sorry, Scot.

Scot: I swear to God. But you know what I didn't do? I didn't look to verify that numbers were moving. I did a rookie mistake. You're right. Here we go.

Dr. Chan: I'm just teasing you, Scot. I make that mistake still to this day.

Scot: Nope. I deserve it. I deserve it. That is as rook as it gets. Like I was born yesterday. Don't act new. All right. Here we go.

Your health is the currency that enables you to do all the things that you want to do, and that's why you should care about men's health. That's the name of this podcast, "Who Cares About Men's Health," giving you information and inspiration to better understand and engage in your health so you feel better today and in the future.

My name is Scot Singpiel. I'm the manager of thescoperadio.com, and I care about men's health.

Troy: I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah, and I care about men's health.

Dr. Chan: I'm Dr. Benjamin Chan. I'm a child and adolescent psychiatrist here at the University of Utah, and I also care about men's health.

Scot: All right. We talk about the core four on the show of course. Troy, why don't you go ahead and remind our listeners what the core four plus one more is?

Troy: Don't make me do this, Scot. You know I can't remember the core.

Scot: That's why we made it the core four, to make it easy.

Troy: I know. Seriously

Dr. Chan: Troy, teach me about the core four.

Troy: Diet, exercise, sleep, mental health, and the fifth one, the one more besides the core four is know your genetics.

Scot: Yeah. Those are the things if you pay attention to will help you stay healthy now and in the future. Of course, mental health is a big one that us guys generally don't talk about or think about that often. That's why we have Dr. Chan on today. So even though you're a child psychiatrist, can you talk to us about adult manly things?

Dr. Chan: I can do it my best. And sure, yes, I'll try to talk about manly things today.

Scot: And for our women listeners, who I know that we have women listeners, no jokes about how having a child psychiatrist on a men's health show is just perfect, because we're not laughing at that joke that we have the psyche of children. Okay? We're not laughing at that.

All right. So, Dr. Chan, before we get to what I wanted to talk about today, which was the practice of showing gratitude . . . we're coming up on Thanksgiving. It's in the name of the holiday Thanksgiving. But a gratitude practice is actually just a really good way, from what I understand, to remain mentally healthy. And I want to get your take on that and talk about that a little bit.

But first, I want to talk about what are you seeing right now as a result of COVID? Have things changed in your practice from a mental health standpoint?

Dr. Chan: They definitely have, Scot. First of all, I just hope everyone is safe and healthy and doing the best they can out there, and I'm glad you're listening to this podcast as a way just to learn more. And yeah, we're about eight, nine months into this pandemic, and we're definitely in a marathon.

Going back to your question how this has impacted mental health, we're seeing higher rates of depression, anxiety, post-traumatic stress disorder across the board. And this has been incredibly taxing for men and women alike as well as for children and adolescents, because we're living in truly unprecedented, challenging times.

How we communicate, how we connect to others has been dramatically altered. Many of us who are used to working are now doing it through Zoom or teleconferencing. Children/adolescents who are going to school have had their school schedules disrupted. It is incredibly hard and difficult right now, and just the amount of stress and anxiety that is placed upon us during these times is just totally new and unexpected and it's just ongoing, going back to my marathon comment.

Troy: Ben, I'll tell you, Scot has run a marathon, I've run a marathon, and I would much rather run a marathon than do this. I'll tell you that. But you're right, it is a marathon. I think we thought that two-week shutdown in March that it was going to be a sprint and we would get through the two weeks and we'd emerge on the other side of that and everything would be back to normal. But I keep telling people, "Hey, circle 2022 on your calendar and maybe that's when things will be back to normal. Maybe."

Scot: Dr. Chan, question for you. So if there's a guy or a person listening and they're like, "Oh, this hasn't affected me. I'm fine," is that generally true, or are we just not in tune to the symptoms that are indicating that maybe we're not fine?

Dr. Chan: So if someone is thinking that they're fine, I would say that is probably true for a small minority of people. The vast majority of us are not fine. And I would argue that if someone feels that they're "fine," I'm not sure that is also true for their loved ones or their family members or the person they interact with at the grocery store or their local school or if they belong to a church.

This is impacting everyone everywhere. And when people are stressed or overwhelmed or feeling isolated around you, it's going to impact you eventually. So even if people feel fine right now, I don't think that's sustainable.

Troy: It is tough. And it's interesting you mention that about maybe thinking you're fine and maybe you're not fine. I've found it kind of interesting these studies that have shown how many people report increased anxiety, depression, etc. And for me, the most surprising thing out of these is that more people aren't reporting that, like it's doubled or . . . What's your take on that? Do you think people are under-reporting or maybe in denial over some of the symptoms they're having?

Dr. Chan: Yeah, there's definitely a denial piece to it and under-reporting symptoms. I think all of us manage our stress differently. I think people are kind of going to extremes, as it were.

Again, this is all very anecdotally because this is unfolding real-time. I've had a number of patients and colleagues tell me that they have children or adolescents who are just bingeing more video games or watching more Netflix or just kind of tuning out reality, turning more towards social media, reading the comment section on social media, commenting on social media. Anecdotally, I'm hearing higher rates of drug abuse or difficulty sleeping.

Right now, one thing that is thriving is all the drive-throughs. So, again, is it a positive coping skill to go to your favorite restaurant? I think it's normal to kind of go out to eat, but going multiple times a week is probably not as healthy, and I think that violates one of the core four as it were.

So I think all of us are running towards coping skills that are not really positive, especially in big doses such as social media, plugging in, eating out. These are all things that people are turning to and that, Troy, is maybe why it's being under-reported.

Troy: Yeah, I was going to say it's funny you mentioned that about eating out. Every night we look at doing something, my wife and I, we're like, "We'll go to a movie. Oh, there are no movies. What about shows? Oh, there are no shows. Let's go eat out again. Let's go to the drive-through." So yeah, I understand that.

Dr. Chan: I've got little kids and we've turned to Crown Burger because they give out free kiddie cones and my kids love those. Again, before the pandemic, maybe we would go on the weekend once and that's turning into more than once a week.

Troy: I know. It's like every other night.

Scot: So us guys can sometimes be notorious for not recognizing when we're stressed, when we're anxious. We just think it's part of life. We just kind of discount those feelings. It sounds like maybe one thing that might indicate that mentally you've got something going on is what you just described. Are you bingeing things? Are you doing some things to excess? I consider those distractions. I'm trying to distract myself from whatever it is going on. It sounds like that might be one indication. What are some other indications?

I mean, it manifests itself differently in everybody, right? So what are some other indications that somebody might be dealing with some mental issues and not even really be aware of it? I've heard getting angry could be one of them. Losing patience could be another. Is that true?

Dr. Chan: Yeah, I agree with that, Scot. That's all true. If you feel your temper, if you're just being short with people, if you're not being as patient, that is definitely a warning sign because that's not who you are. But I think everyone right now is stressed, and stress, again, as we talked about, manifests itself very differently.

Another one that came into my mind too, Scot, is just lack of concentration, the inability to focus. I don't know how many people I've talked to told me that projects that used to take a short amount of time now take a lot longer. That book you pick up at night to read, now people are tuning out after a couple of pages. It's just much more difficult to focus right now, and that is definitely a warning sign of stress, depression, and anxiety.

Troy: Maybe it's just me, but it seems like on the road people are just edgier, like more aggressive drivers. And there's certainly been an increase in traffic fatalities and they've said, "Well, it's because there aren't as many people on the road, so people are driving faster." But I wonder if that's a manifestation as well. People are just kind of edgier and more aggressive and maybe one other symptom of this we're seeing as well.

Scot: So if you notice some of these symptoms, of course that can impact your health, not only your emotional health but your physical health, as Dr. Chan said. Maybe if your outlet is drinking too much or eating the wrong kinds of foods too often, that might not necessarily be healthy. So what are some things that one could do to perhaps put themselves in a better mindset?

Dr. Chan: First of all, we cannot take care of people around us if we cannot take care of ourselves. So I've been more and more preaching self-kindness, self-awareness, taking breaks. I know we talked about a marathon earlier, but I really advocated exercise and going for walks just to start healing yourself. And that helps with sleep. That helps with body regulation.

I really believe that we just need to be less hard on ourselves, because going back to what I said about the projects . . . and I'm guilty of this too. I'm not responding to emails as quickly. I'm not as effective in a meeting because our brains aren't used to Zoom.

The cognitive load of trying to balance all these different things with my team across . . . everyone is working from home. Everyone is working remotely. Things just take longer. And so I'm just trying to be much more patient both with my family as well as the people I work with, just knowing that everyone is doing really the best job they can. And people's efficiency is not as strong as it once was.

Scot: Troy, do you have a gratitude practice in your life?

Troy: That's a great question, Scot. I know you've mentioned you do journaling and that's something I do as well. I think since we've talked about it, I've tried to do that more consistently on a daily basis. And as part of that, I do try and think through some of the things I'm grateful for.

It is sort of a process every morning of doing that. And so I've long believed that gratitude and expressing gratitude and feeling gratitude certainly makes a big difference, and it's probably become a lot more important to me during the pandemic and during what we're experiencing.

Scot: Yeah, you're right. I do journal and I try to come up with three things I'm grateful for every day. And some days it's really hard, but I find that just the act of looking for that makes me feel better about things. And sometimes that gratitude might be, "Hey, you know what? I learned a new skill today," or, "Hey, I got this major project done," and it gives me a chance to be grateful for something that I might not have necessarily thought about and then would have just let my mind go, "All right. What do you have to do next?" It's like a little party, a little celebration.

Dr. Chan, do you have a gratitude practice, and has it been proven to help people feel better and actually help their mental health?

Dr. Chan: I do have a gratitude practice. I like to send thank you notes. And especially in today's age of email and social media, I really feel like a handwritten letter of gratitude goes a long, long way. All of us on this call used to remember a time when we would run to the mailbox to look for mail. Now, email comes to us instantaneously, but I still think a really nice, well-written card or letter really can touch people in a positive way.

As I alluded to earlier, I think people are looking for a way to connect to others. And even if you can't meet with your loved ones, even if you can't meet with your team, your work colleagues, I still think there are other ways to express gratitude.

So the research has shown that people who express gratitude have lower rates of depression, increased rates of happiness. They feel connected to others. There's a warmth there. There's an ability to have empathy.

Again, all of us are working incredibly hard. Everyone is doing the best job they can. And to have a meaningful way to say thank you goes a long, long way to feeling that you were listened to and heard.

The research also talks about the ability to form alliances and building trust between people when you express gratitude. I know this is a men's podcast, and so I was looking up some other literature, and there's this old stereotype that I'm not sure if all of you have tackled, that men are a little bit less likely than women to express their emotions. I think this gratitude concept falls into that. Men are slightly less on average -- again, it's a very stereotypical comment -- to express gratitude to others as opposed to women. So I think there is something there.

Again, let's use this time as an opportunity to say things and have men thank the people around them for either the love or the jobs well done.

Troy: Ben, it sounds like it's not so much, like Scot and I are talking about, just writing it down. It's more that expression of gratitude and that connection that comes to others as we let them know we're thankful for what they do, we're thankful for their role in our lives, or whatever that may be.

Scot: Troy, I think we've been doing gratitude wrong. Dr. Chan, I thought the gratitude practice was finding two or three things every day that you were thankful for, but it sounds like truly it's reaching out and connecting to somebody. Or are they both gratitude practices that could give you benefits?

Dr. Chan: Well, Scot, I would say both the way you phrased that. The gratitude practice, yes, you can identify two or three things every day that you're grateful for. But again, we're in a pandemic. People feel isolated, people don't feel listened to or heard, people are feeling a little scared, so I think this is an opportunity to connect to others and give thanks for who they are and what they are in your life.

So if I asked all the listeners out there, "Who are the five people you're most thankful?" some of you will think about your wives, yours husbands, your partners. Some of you may think about your friends. Some of you may think about your coworkers. When is the last time you said thank you to them? When is the last time you took a break, took a pause, and connected with them, and just genuinely let them know you're appreciative of who they are and what they are to you?

To me, that's Thanksgiving. That's what we're trying to do. And so, yes, I would argue that there's a connection aspect to it.

Scot: Troy, I really appreciate that you're in my life.

Troy: Thanks, Scot. And I appreciate that you're in mine, and, Ben, I'm grateful you're on our podcast.

Dr. Chan: This is so cheesy. I love it.

Scot: What I'm getting at, though, is that feels weird. Even though I grew up on a ranch, which has its own stereotypes. My dad was as stereotypical of a rancher as you could get. I'm a little bit more sensitive, as my mom likes to describe it.

And sometimes when I do say things like that to other men, like, "I really appreciate that you did that for me. Thank you very much that . . ." and I maybe might give a specific reason why that made a difference to me, I feel like guys pull away from that, like I'm stepping over some line I shouldn't have stepped over, like I did too much.

Dr. Chan: Yeah, you don't need to do it on a podcast in front of hundreds of thousands of people who listen to this.

Troy: I think you underestimated our numbers, Ben, but go on.

Scot: We'll forgive you.

Troy: We'll forgive you.

Dr. Chan: But think about how hard you worked on a project, Scot, and if someone, your boss, your supervisor, we all have bosses, we all have supervisors, just that short little email, like, "Hey, Scot, that was a great job," how much that would mean to you.

So I'm not saying it has to be in person or over a podcast. Everyone accepts praise. Everyone accepts that ability to connect in different ways. And I think that's who we are. We as humans have different ways of communicating our emotions to others.

So I guess what I'm saying is this gratitude idea, this gratitude project, what are some ways you can express gratitude to those around you? And it might be a handwritten note, it might be an email, it might be a phone call, it might even be a text.

I mean, my best friend from high school I don't talk to very often, but I get really sweet texts from him every once in a while and it just makes the world to me, and I save all of those. So I think you just have to know your audience. Who are the people you're trying to connect with?

Troy: I'm feeling guilty now. I feel guilty. I'm thinking about my best friend from high school. I haven't been in touch with him in probably seven or eight years. Like you said, this is a time where I think we just need so much more connection and just a text or something to say thank you to someone. I'm sure it means a lot to that person, but just personally, to have that connection, I think, can help us out a lot as well.

Scot: Dr. Chan, I think you've given us all a really great idea as we head into Thanksgiving, especially a Thanksgiving unlike any Thanksgiving that we've had. It might be a Thanksgiving where we might decide as a family unit, each one of us, that perhaps getting together with other family units as we have in the past is not necessarily a great idea this year, but there are other ways, it sounds like, you can reach out and let somebody know that they matter to you and they mean something to you.

And it doesn't necessarily have to be a family member. It could be a friend, somebody you haven't talked to in seven years, and you don't have to go all Scot on them. You don't have to get all gushy. Maybe start with just a thank you and then see how they accept. You described your interaction with your friend as these sweet texts, which to hear a guy say that about a text from another guy is a little strange.

Dr. Chan: But as a psychiatrist, I like to feel that I'm in touch with my emotions. The people in your life, be it men or women who care about you, they'll communicate that to you in very profound, meaningful ways.

All of us have bad stuff happen in our lives. I mean, the thing that's impacting all of us right now is a pandemic, but all of us have had breakups, we've had loved ones pass away, we've received failing grades, we didn't get that promotion at work. And just those negative emotions are really difficult. How do you leave them when someone reaches out to you that cares about you and just lets you know they're thinking about you and you can share some of that burden with them?

So I say sweet texts. I can just think of moments in my life where I felt pretty down and my best friend reached out to me and just let me know he was thinking about me and he was thankful that I was his friend, and that just meant a lot to me. So that's what I meant by sweet texts.

Troy: Scot, I didn't even think twice. I thought Ben was just like, "Sweet, man. That was so sweet."

Scot: Sweet text.

Troy: "Sent me this link to this awesome ACDC video."

Scot: I love your challenge, Dr. Chan. Think of five people that mean something to you, reach out to them, let them know. Even if it's just reaching out to say hi it sounds like.

How many times have each of us or any of us just been like, "Wow, I haven't thought of that person in forever, and we were so close at one point"? Well, when they pop in your head, then sometimes you're like, "Well, maybe I'll reach out," and then you're like, "Nah, I don't want to interrupt him or anything." Maybe instead of going that path, you go the path of reaching out. That might be a good place to start.

Dr. Chan: I mean, the weird thing is, and I talked about this too, we exist in this culture right now where we spend hours Netflixing and bingeing or social media-ing. But compare that to how many times you've had like a real conversation with someone you care about in your life. I mean, the ratio is dramatic. That's why I'm just kind of recommending and talking about just connect with others.

Scot: Get out of Twitter. Maybe text or call a friend and show a little bit of gratitude this Thanksgiving. It could do wonders for your mental health.

Dr. Chan, thank you so much for being on the podcast, and thank you for caring about men's health.

Scot: Paging Dr. Troy Madsen to Scope Studio for "ER or Not."

"ER or Not," that's where we throw out a scenario for you, you decide whether or not it's something to go to the ER or not, and Dr. Troy Madsen is going to let us know whether or not you guessed correctly.

Today's "ER or Not," you have some food stuck in your throat. I'm talking about you're breathing fine, it's not obstructing your airway, which is definitely always a reason to go to the ER if that airway is blocked, but it's just there and it won't come up, it won't go down. It's uncomfortable. ER or not?

Troy: Well, this is one of those things, again, emphasis on it's not affecting your airway. It's just something you feel is stuck in your throat. People often point to the base of their neck. They can't swallow even their own saliva. They're just spitting it out.

It's something you very well may have to go to the ER for, but there's a trick you can try at home before you go to the ER. And that is take a soda, usually a Cola, and try and drink a little bit of it down or get some of it down where it's not coming back up and let it sit there. Now there's something about soda, and Cola in particular, where it can relax the esophagus. And it's a trick you can try to potentially get that food to pass and get down to the stomach.

So this is something that you may avoid a trip to the ER for because your only other option is to come to the ER. You can't go to an urgent care for this. You have to come to the ER, ideally a larger ER, a center that would have a gastroenterologist on call because they're going to have to come in and retrieve that piece of meat or whatever it is and either push it down to the stomach or pull it out.

Scot: The soda route sounds like a thing to try first before you do that.

Troy: Absolutely. If it were me, I would try and grab a soda. And again, the challenge is sometimes that it's obstructing things so much that you're even spitting up your own saliva. But if you just feel like something is stuck there, try and get some soda down there. Just let it sit there, five minutes, see how you feel. Give it another five minutes. For me, personally, I'd try three or four times, and if it's just not working and nothing is going down, then you've got to get to the ER.

Scot: And again, to stress, in this scenario, you've got something stuck in your throat like a piece of food, but it is not obstructing your breathing. It might be causing that you can't swallow your saliva, but you can breathe okay.

Troy: Right. Anything that's obstructing your breathing, that's something you need to get immediate help for. Even then, not just ER, but call 911.

But if you do this and it's not obstructing your breathing and you drink the Cola and it resolves, you probably still should get in to see your doctor. You may sometimes have these rings in the esophagus, little things that food get caught on, that it would be worth having an endoscopy done at some point to look to see if that's there to prevent future problems. But no rush to do anything once it resolves.

Scot: "Just Going To Leave This Here." It's a part of the show where we might talk about something having to do with health or something that's going on in our life, or it could be something completely random and fun hopefully.

Troy: Hopefully. It's always questionable.

Scot: It is questionable. We'll see. Here we go. Just going to leave this here. I've made an observation about myself and I want to know if other people have this same kind of issue. If you give me a decision, which line to choose in the grocery store or which lane of traffic to choose when I'm driving somewhere, I'm always going to make the one that takes longer. Always.

Troy: That's the rule. That's how it always works.

Scot: I'll be standing in a grocery store line or I'll choose between two of them and I'm like, "That one looks like it might be faster." And as soon as I get into it, inevitably that's going to be the one that takes longer.

Troy: Every time at the airport. You've got four lines to choose from and I always choose the wrong one.

Scot: I don't know why that is, but that's my "Just Going To Leave This Here."

Troy: I'm glad I'm not alone in that. I'm just going to leave this here. You said this could be interesting and fun, so now it's not because I'm talking about science fair. My nephew just competed in science fair.

Scot: That's awesome.

Troy: Did you ever do science fair?

Scot: I did. I got the people's choice award for my telegraph, which would have been a great science . . .

Troy: You invented the telegraph? Scot . . .

Scot: Which would have been a great science fair project in 1890.

Troy: A hundred and fifty years ago, it would have been awesome.

Scot: But I don't know.

Troy: You would have been a thousandaire by now.

Scot: Yeah. It was a study in magnetic because that's how old telegraphs worked. But that was what intrigued me. My friend, by the way, did a solar-powered engine, so he was way on the cutting edge of things.

Troy: Oh, wow. He was on it.

Scot: Before solar power.

Troy: So my nephew did a project. He looked at golf balls, and he had these golf balls soaking in water for various periods of time to see how it affected how far they would bounce and fly. The idea being that he would fish golf balls out of streams by golf courses and sell them to golfers. He found they don't work as well. It was a cool little project, just a fun kind of idea.

I'm just such a nerd. I did science fair when I was in high school and junior high. This is what I actually did. I actually took soda bottles and did swabs on those bottles to see how many bacteria are on soda bottles, and it was disgusting. This was the stuff you'd buy out of vending machines.

Scot: Oh, so a vending machine soda bottle?

Troy: A soda can. I shouldn't say a soda bottle. A can that you're putting your mouth on and drinking out of. So not a bottle.

Scot: That has not been opened. So you'd go to the store or vending machine, you'd buy one of these, and then you'd swab it, and then you'd see what's living on it.

Troy: Yeah. And this is what we're putting our mouths on. So that was my science fair project, was taking soda cans out of vending machines and from stores, doing a swab, and then growing it and seeing the stuff that grows there.

Scot: Nasty. Like stuff that could impact our health?

Troy: Potentially. I don't know. I never . . .

Scot: You didn't quite get that far.

Troy: I didn't quite get that far. I did not isolate the exact strain of E. coli that was on there.

Scot: There wasn't E. coli on there, was there? I don't want to start rumors on the show.

Troy: I'm going to have to go back to my science fair project, so don't quote me on saying there was E. coli.

Scot: We'll look at the data. I know people that wash off or wipe off the top part of their soda cans before they use it. So that might not be a bad idea.

Troy: I would. Even if it's coming from a box, it probably sat in some factory for a while, and there's a certain limit on the number of rat hairs and the amount of . . .

Scot: Oh, come on.

Troy: I'm not joking. You can have X number of rat hairs . . .

Scot: Oh, I see.

Troy: . . . and X amount of rat droppings and urine within some kind of facility that still meets health code. I know this is disgusting.

Scot: And we're not saying that's actually on there, but the potential . . .

Troy: I'm not saying there's rat urine on the . . .

Scot: There's an acceptable range as opposed to not an acceptable range, which I would think . . .

Troy: Exactly. Some is acceptable. Anyway, this is a long way of saying that science fair is great. I enjoyed the process of discovery, and it's fun that kids are getting into this. So that's my "Just Going To Leave This Here."

Scot: All right. There you go. That took a completely interesting path.

Troy: It sure did.

Scot: And that's sometimes what happens with "Just Going To Leave This Here."

Troy: Exactly.

Scot: Time to say the things that you say at the end of podcasts because we are at the end of ours. First of all, thank you so much for listening. It means a lot that you're taking ownership of your health and you're getting some information and inspiration here. If you haven't yet, please subscribe so we can be a part of your life every week.

Troy: Yeah. Subscribe through anywhere you get your podcasts. You can check us out on Facebook, facebook.com/WhoCaresMensHealth. Our website is whocaresmenshealth.com. You can contact us, hello@thescoperadio.com. Thanks for listening and thanks for caring about men's health.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Health is more than just diet and nutrition and how you look in the mirror. In order to live your best life, taking care of your mental health is crucial. Your mental state allows you to feel good about yourself, be confident to live the life you want to, and have positive, enriching relationships.

Kevin Curtis is a licensed clinical social worker with University Neuropsychiatric Institute. He suggests asking yourself three questions to assess the state of your mental health:

• Are you having thoughts that are useful to you?
• Are you having thoughts that impact your ability to function?
• Is your emotional state supporting or hindering achieving your goals?

Kevin is joined on this episode by his friend Ben. Ben works at the University of Utah and considers himself a regular guy who has been working with professionals to improve his mental health over the past decade.

Ben admits that he's not the paragon of mental health, but feels tons better than he was 10 years ago. He's learned a few tools and techniques that have helped improve his mental health over the past 10 years. He shares the three tools he feels were the most helpful for him.

1. Box Breathing/Tactical Breathing
   The way you feel during an emotion is ultimately a physical response. The increase in heart rate when anxious. The flush of blood to the face when angry. These physical changes can start a feedback loop with your emotional state that can lead to an overwhelming response.

   To help keep your mind calm when feeling stressed, Ben focuses on his breathing. He will breathe in for a count of four. Hold that breath for a count of four. Breath out for a count of four. Pause for a count of four. Repeat as necessary. This is called "box breathing."

   This breathing technique allows you to shift your mind to a physical response rather than an emotional one. It changes the way your body feels, and in turn is able to help make the emotion feel less overwhelming.

   Tactical breathing uses the same four-second breathing technique but removes the pauses between breaths. This alternative will provide the same benefit, but is best used in a situation when you need to be able to breathe regularly.

2. Check fo BLAST(H) Conditions
   We've all had a friend, partner, or child in our lives that make poor decisions or are particularly irritable because something more physical is going on. It's sometimes easy to see exactly why another person is stressed, but hard to recognize it in yourself. As such, Ben's second technique takes a personal inventory of the following if you are feeling overwhelmed:

   B: Bored
   L: Lonely
   A: Angry
   S: Stressed
   T: Tired
   H: Hungry

   If these "BLAST" conditions are present, recognize they may be having an impact on your emotional state.

   A good step to improve your mental health is to adopt strategies and daily habits that will keep you out of these conditions as often as possible.

3. The Reach Out
   While professional help can be an integral part of your mental health strategy, it's also important to build a network of support and "emotional scaffolding" with people in your life and network.

   "The Reach Out" is a technique that aims to build and strengthen your connection with others. If you are feeling down, or upset about a situation, reach out to two people you trust. These people can be friends, family, coworkers. Take the opportunity to tell them what is going on in your life and how you feel about it. Explain that you are not seeking solutions to your problems, but rather you are merely reaching out to let them know what you are experiencing.

   By expressing vulnerability without setting an expectation, you are inviting these people to join a network of support without placing pressure on them. Additionally, by reaching out and getting personal, you are inviting the possibility of sharing a meaningful interaction that can deepen the bonds you have together.

In times of stress, be sure to take care of your mental health. These tips may help maintain and improve your day to day mental resiliency. However, if you are experiencing overwhelming feelings of depression or contemplating self-harm or suicide, reach out to a professional.

For people in Utah consider the Crisis Intervention Services at University of Utah Health. Talk to Us

If you have any questions, comments, or thoughts, email us at hello@thescoperadio.com.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Dr. John Barrett is a family physician and the Executive Medical Director of the Community Physician Group for University of Utah Health. He reached his own health turning point over a decade ago.

Dr. Barrett found himself giving in to the anger and frustration that comes with being a physician. Like many men, this stress and frustration was actually a sign of depression. He was able to identify the symptoms in himself and seek help.

After reaching out to loved ones and working with professionals, Dr. Barrett was able to work through his mental disorder. It took over a year of talk therapy and medication to get his mental health back to a place where he could thrive.

"Down south I was what we would call 'a mess,'" says Barrett.

These days, Dr. Barrett is always on the lookout for signs of his own mental health. Whenever he notices a warning sign he focuses on self-care, focusing on his physical health, and reaching out to professional help before things get worse.

Like most health concerns, Barrett's mental health is something he's continually working on, but he feels more in control of his own mental health and wellbeing today than he did a decade ago. Telehealth: More Options for Medical Access

Dr. Barrett works with the Telehealth group at University of Utah Health, and he's seen first hand some of the applications emerging technology can have in the healthcare space. But first, what exactly is telemedicine.

Telemedicine is the means of providing healthcare access from a patient to a health professional using digital means like text or video chat through a computer or smartphone.

At University of Utah Health, in-state patients can call in via an app or web portal to speak directly to a general practitioner through a video call. For University of Utah employees and patients with a University of Utah Health insurance plan, these video calls are covered by insurance. For other patients in Utah, there's a flat $49 fee that will be refunded if the call is escalated to an in-person visit. What Can a Doctor Do Over Video Chat?

According to Dr. Barrett, the best way to think of a telehealth video call is like "virtual urgent care." Half of the patients calling in are given advice and counsel about whether or not they need to see a doctor in person. The other half are given a diagnosis of a relatively minor medical condition. And a very small percentage of patients contact telemedicine services with a concern that needs to be escalated to emergency care.

When a physician diagnoses a condition over a virtual visit, they can prescribe medications necessary for treatment. Dr. Barrett shares a story of a woman who was out on a camping trip in the Wasatch Mountains. After suspecting she had a urinary tract infection, she drove her car back down far enough to get cell reception. She was able to call a physician, get a diagnosis, and a prescription for an antibiotic right over the phone.

A large portion of the phone calls the telehealth team receives is from young new parents. When your kid is sick, it can be stressful. It can be difficult to determine if it's an emergency or if you can wait to seek help the following day. A quick video call to a physician can help to diagnose most pediatric concerns and help put a parent's mind to rest.

Other growing telemedicine fields include dermatology, where specialists can diagnose rashes and moles with pictures or videos. New services are also developing ways for people to access mental health services through text and chat. How Can I Access Telemedicine?

For Utahns, you can use the digital health services at University of Utah Health through the MyChart app if available, or visit healthcare.utah.edu/telehealth for more information. ER or Not: Broken Nose

Scot recently came across a skateboarder on campus whose face was covered in blood. There were no signs of a head injury, but the kid had broken his nose. Scot tried to help but he wasn't sure where to send him. Urgent care or ER?

According to Troy, a broken nose is no reason to go to an emergency room or an urgent.

As long as the person with the broken nose has not been knocked out, nor are dealing with a head injury, a broken nose is nothing serious. These days, if a patient comes to the ER with a broken nose, there's not much they can do to treat it. No big tubes of cotton stuck up the nose. No "setting of the broken nose." Nothing.

In most cases of a broken nose, the amount of swelling present limits the options doctors have for any type of treatment. The swelling must go down before any corrective measures can be taken.

Troy suggests that if you have a broken nose, wait a week for the swelling to go down, then go visit an ear, nose, and through (ENT) specialist. They will be able to better assess the damage and create a treatment plan after the swelling has gone down.

There is one caveat to this advice. If you look in the mirror up your nose and there's something on your septum that looks like a grape, you may need to go to the ER. This type of growth is called a nasal septal hematoma. It's essentially a big sac of blood that forms after an injury. When one of these hematomas grows in the nose, it can potentially erode the septum leading to potential structural problems. These hematomas are rare, but need immediate treatment if found. Housekeeping - We Have a Winner!

We announce the winner of the Who Cares About Their DNA Giveaway. For the last 6 weeks the guys at the Who Cares Podcast have been looking into the complicated issue of at-home genetics testing and calling for submissions for people interested in winning one of these kits and the opportunity to be on the show.

Our winner is listener Matt. Matt is thirty years old and he says this about wanting the test:

"I want to know more about my body, based on the things that are out of my control. A genetics test can help me understand what chances I have of developing certain disorders or what ones I could pass on to my children."

We'll be reaching out to Matt to speak with him about the aspects of these tests we've been exploring and have him on the show.

Thank you to everyone who participated! Just Going to Leave This Here

On this episode's Just Going to Leave This Here, Scot has made a serious caffeine mistake. Troy muses about the first dog in space. Talk to Us

If you have any questions, comments, or thoughts, email us at hello@thescoperadio.com.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Dr. Jeremy Thueson is the director of outpatient recovery services at University Neuropsychiatric Institute (UNI) and he cares about his health. Jeremy had his wake-up call during his medical residency. With the long hours, poor eating habits, and stress of residency, he started putting on weight. He hit a lifetime high and his BMI qualified as overweight.

Jeremy fit the medical definition of overweight, and he was over it.

"It's easy to try and be drastic and overhaul everything," says Jeremy, explaining that a lot of guys will immediately go get a gym membership and throw all the food in their cupboard away after they decide to get back in shape. But those changes aren't sustainable for most people.

To lose the weight, Jeremy tried "staying more aware" and started making small manageable changes in his lifestyle. He got a pedometer started walking more in his daily routine. He downloaded a calorie tracking app and actively reached for a piece of fruit rather than his typical bag of chips. Rather than trying to hit the gym hard for an hour a day, he fit in more manageable 15 minute exercise breaks when there was free time in his busy schedule.

Over the next six months to a year, those changes added up, and Jeremy's weight is back under control. He admits that his diligence waxes and wanes through the year. Specifically, he has difficulty exercising during the winter - he hates the cold and doesn't like to go to the gym - but it's something he's mindful of and "course corrects" where he can. The Big Picture Problem of Opioids

Opioid addiction, or opioid use-disorder, affects the lives of many Americans. And the overdose deaths related to those drugs are an epidemic. In 2017, a little over 70,000 people died in the U.S. of drug overdose. In the state of Utah, 450 people die every year from opioid overdose. That's one to two Utahns dying every single day.

While those numbers may seem staggering already, Dr. Jeremy Thueson believes that the numbers are actually underreported.

Opioid overdose impacts more than just the people struggling with addiction. Troy's emergency department has recently completed a pilot study investigating the community impact of overdose deaths. The initial study asked 200 patients in the ER if they had a family member die of opioid overdose. One-third of patients responded that they had lost someone to opioid overdose death.

These deaths are often accidental or unintentional. Many people with opioid use disorder are completely unaware how close to an overdose they are. Some use high amounts of the drug to feel normal and other will accidentally mix their meds with other substances like alcohol unintentionally.

These deaths are mostly preventable, through education on the disorder, proper treatment, and overcoming the social stigma related to addiction. How Do People Become Addicted to Opioids?

It's important to remember that there is no specific "type" of person that becomes addicted to opioids. Opioid addiction crosses all demographics and sectors of society. Many people struggling with opioids are high functioning. They work in the business sector. They're physicians. They're parents.

Opioid addiction, or opioid use disorder, usually begins with a patient being prescribed the drug through legitimate means. Whether it be surgery, wisdom teeth removal, etc. the patient is first exposed to opioids for acute pain management. Then slowly increased use creeps up over time. It can be years of slightly increased use before people realize they're addicted. Many People Use to Prevent Withdrawal, Not to Get High

In the ER, Troy has first hand experience with opioid use disorder. One individual shared his experience with Tror and a group of physicians. This man explained that he was no longer using opioids to get high, but to avoid getting sick from withdrawal symptoms. For this man, the opioid withdrawal is so horrible, he would do anything to go through it. So he continued using the drug.

Whatever upside people experience using opioids ultimately has diminishing returns over time. Very early in the timeline of opioid misuse, addiction and physical dependence will take hold of the user. For these individuals, they can suffer severe withdrawal symptoms if they don't get their opioids.

"It's a horrifically stressful way to live," says Dr. Thueson, "it's very taxing on your body and mind. It's hell. People are not enjoying that for very long."

To compound the problem, there is a tendency in medicine to minimize the experience of opioid withdrawal within the medical community. Most physicians are taught that opioid withdrawal is not considered "medically dangerous." While the mortality risk of opioid withdrawal is lower than other substances like alcohol, the experience is every bit as awful for opioid users. According to Dr. Thueson, it's not uncommon for people to become suicidal while experiencing the pain of withdrawal.

There is a lot of shame, guilt, frustration navigating the system to get help with recovery. And for most of these people dealing with opioid addiction the fear of withdrawal is what keeps them in the cycle of substance abuse. There Are Many Barriers for Treatment

Many people who find themselves reliant on opioids have an element of denial about their situation. There is a very real fear of speaking up about their problem and how it may impact their personal and professional life. There isn't a lot of socially acceptable ways to speak about having opioid addiction without facing judgement.

There is still a social stigma today about opioid misuse. It can often be framed as a moral weakness or character flaw in the person suffering.

"There's more debate about [opioid addiction] than I'd like to see," says Dr. Thueson, "The best evidence we have now is to conceptualize this as a medical problem that needs treatment, like anything else. And not something else we need to be shaming people for ending up in that situation. I have not yet seen a patient who set out to get addicted to opioids." The Best Opioid Addiction Treatments Available

The standard of care for opioid use disorder in 2019 is medication. There are three FDA approved medications available that have proven effective:

Methadone - A medication that has been used for 40 years in the U.S. to treat substance abuse. It's proven effective at helping treat withdrawal and minimizing cravings for opioids.

There are a few drawbacks to methadone. First, the treatment itself can prove cumbersome. Each dose of the medication is given in a clinic or office every day of treatment, which can be difficult. Those clinics must be officially licensed by the federal government to provide methadone. Additionally, there are many challenges and risks with the use of methadone.

Buprenorphine - Often known by the brand name Subutex, this medication treats opioid withdrawal and cravings through a prescription drug that can be taken at home. For a majority of patients, it has been proven the best balance of risk and ease of use. While the drug doesn't need to be dosed in an office and clinic, it can only be prescribed by a licensed physician.

Naltrexone - Unlike the other two medications, naltrexone is an opioid receptor blocker. The medication helps minimize cravings by preventing the body's reaction to opioids. Without the positive effects of taking the drug, patients are less likely to use it.

The drug can be administered through an oral medication or a once a month injection.

In addition to medication, behavioral therapy can help patients get off opioids. These mental health treatments can include individual and group psychotherapy, mutual support groups, and formal recovery programs.

Medications in concert with behavioral therapy is the frontline treatment against opioid addiction. How a Person Can Get Help

Once a person has decided to seek treatment for their dependence on opioids, there can be many barriers between them and the proper treatment and resources. Treatment can be a non-starter for a majority of people without insurance or financial means.

In Utah, the University of Utah has created a program to help people struggling with opioid addiction. The BRIDGE program is run through the emergency department. If a patient is experiencing opioid dependency or suffering from withdrawal symptoms, they can go to the ER and receive immediate treatment. Patients are given an initial buprenorphine dose as well as a prescription for the initial month of medication. After receiving the medication they need, they're referred to an outpatient clinic that can continue treatment by developing a custom tailored long term care program

There is no cost to the patient. The program is state funded by a grant that aims to fight the opioid epidemic in Utah. The goal is to get the patient's addiction stabilized and their head clear so they can focus on the other struggles in their life.

For people not in Utah, there are similar programs available in other states. Patients should speak with their primary care physician or go to a clinic to get professional help and find out what resources are available for treatment.

Remember, doctors are required to have a federal waiver to prescribe substance abuse medications. It's important to find out what doctors, centers, and facilities are permitted to help treat opioid addiction

Use the SAMHSA online database to find a provider near you that can prescribe these drugs.

For a lot of people in withdrawal or actively using, navigating the already complicated system can be impossible. Programs like BRIDGE and certified physicians can help individuals get the help they need.

"Until we make this as easy as staying on heroin, we're making this tough on people," says Dr. Thueson. He urges fellow physicians to step up and get certified to give the federal waiver. "We need to step up and stay aggressive so we can help treat [opioid addiction]" Just Going to Leave This Here

On this episode's Just Going to Leave This Here, Troy wonders how the new marijuana breathalyzer is going to be used the cops and Scot is finding a new appreciation for bodyweight exercises as he tries to fit exercise into his busy schedule. Talk to Us

If you have any questions, comments, or thoughts, email us at hello@thescoperadio.com.

Interviewer: It's another edition of "ER or Not" with Dr. Troy Madsen. All right, go ahead and play along, and see if you can figure out the answer to today's situation. Dr. Madsen, today's "ER or Not" a panic attack. Is that a reason to go to the ER or not?

Dr. Madsen: That's a tough one, because I think, for some people they absolutely feel they need to go to the ER, and typically, what's going to happen is, in the ER, is you might get some medication to help calm you down, give you a little bit of time to relax, but it's probably not something you absolutely need to go to the ER for. If you've had a history of anxiety before, you may have some medication at home you could take that can kind of help calm you down. You know, take 30, 45 minutes before you make that decision to go to the ER.

Of course, the big reason to go to the ER would be if you're having other issues, as well. Let's say you're having thoughts of hurting yourself, you know, any thoughts about suicide, absolutely you need to get to the ER. And that would be the biggest thing I'd say. You know, when someone comes in saying, "I'm just feeling really anxious," they're hyperventilating, that's my first question. "Well, are you having thoughts about suicide, any attempts, anything like that, that we need to be worried about?"

Interviewer: But the panic attack itself and the hyperventilation, that's not a breathing issue, generally?

Dr. Madsen: Well, that's a great question, and I think there are kind of two things here. There may be a person who's had panic attacks before, they've been diagnosed with anxiety, they're familiar with this feeling. If you're in that situation, you may have medication, you may know how to kind of control things at home. Maybe you've tried some deep breathing, things to calm yourself down.

Now, on the other hand, if, just out of the blue, you've never experienced this and you suddenly start to feel extremely anxious, you're hyperventilating, you know, you may think to yourself, "Well, maybe this is just a panic attack," but something like a blood clot in the lungs can cause a person to feel very anxious, very short of breath. It gives you that feeling like you're going to die, something that a person with a panic attack might feel. So you've got to be careful there, and if that's something you haven't experienced before, then absolutely, I would say you need to get to the ER.

updated: May 6, 2020
originally published: September 29, 2017

Interviewer: What should you do if someone you know has a very severe asthma attack? We're going to find out next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From the University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Madsen, I want to do a scenario here. If somebody has a very severe asthma attack, and I'm there, what should I do? I would imagine that that person knew they had asthma, and I'd hoped they had an inhaler. Would that be the first place I'd start?

Dr. Madsen: Probably so, but you also have to think, is this someone you just need to call 911 for and get them to the ER. And in my mind, the way I really judge the severity of an asthma attack is, first of all, can the person talk to me? If a person cannot breathe well enough, where they can't really get out more than say a one word answer, that's really severe. And in that situation, before I go looking for their inhaler, I'd say call 911. Get the ambulance there, get them to the ER, because even if they take a couple of puffs of their inhaler, it's probably not going to do much in that situation.

Interviewer: All right, so super severe like that, don't even mess around with it, don't hesitate, call 911, get the professionals there.

Dr. Madsen: I would.

Interviewer: And if they're not quite that severe, they're able to get some sentences out, they're able to talk to you, what would you do at that point?

Dr. Madsen: Usually in that situation, if they have asthma, they have an inhaler somewhere, and so they might say "Hey, can you go grab my inhaler for me?" Maybe they're feeling kind of winded, they just want to sit down, try and relax a little bit. But they're talking to you, they're not breathing so fast they just can't get anything out. You look at them, they look like they're working a little bit to breathe, but it's not like when they breathe you see all of their neck kind of sucking in because they're trying to get air in. So it's not a real severe case, so certainly I think an inhaler is going to help there.

Even in those situations, if it's that bad they might take a couple of puffs of their inhaler, they might feel a little bit better. But I often find even in those scenarios, they may need some more treatments in the ER, including possibly steroids which are going to help out as well, which typically they don't have at home.

Interviewer: All right, one of the ABCs is breathing. And any time that somebody is having trouble breathing, that is one of the rules that you use that you should go to the ER. So it's crucially important. What should you do at that point, while you're waiting for help to arrive, whether it's the inhaler didn't work, maybe they didn't have one, they ran out, they are struggling breathing. Is there anything you can do to help them at that point?

Dr. Madsen: Really the best thing you can do is whatever you can do to just keep them calm, because if someone is having trouble breathing, that's going to make you feel anxious. You can just imagine that drive you have to breathe, and when you're struggling with that you're going to feel incredibly anxious. The problem with asthma is that anxiety is going to make it even more difficult to breathe, it's just going to compound the problem.

So realistically, the only thing you can do there besides say having them take some puffs of their inhaler, would be to do whatever you can do to help them calm down. Turn on the TV, turn on some music, something just to help them relax a little bit, while you're waiting for the ambulance. Reassure them they're going to be fine, tell them you're breathing okay, you're talking to me, this is great, ambulance should be there hopefully within 5 to 10 minutes. And at that point, they're going to get them on some continuous breathing treatments and get them where they need to be.

Interviewer: So in summer, it sounds like if somebody is having a severe attack like that, just call 911 because there are things that you can do in the emergency room to help them, and just a breathing problem is not something you want to mess with.

Dr. Madsen: That's exactly right. Like you said, we talk about the ABCs, that's what B stands for. Once you talk about breathing, you've got to address it, and usually you're not going to be successful at home. Keep in mind that asthma is a very serious disease. It kills thousands of people every year, so you have to take it seriously to get them the help they need.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: Sepsis. What is it, how do you get it, and what should you do about it? That's next on The Scope.

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician. I wanted to learn a little bit about sepsis today. What exactly is sepsis? Let's start there.

Dr. Madsen: Well, sepsis is, you know, a word you may have heard, but the best way to think about sepsis is it's just an infection that started somewhere, either in the lungs or the urine or on the skin, like a urinary infection, a skin infection, that then works its way through the entire body. So it's basically just a full-blown form of stuff that otherwise might not seem like that big a deal, that you could just take some antibiotics for.

Interviewer: All right, so a localized infection is not sepsis?

Dr. Madsen: No.

Interviewer: It's when that infection somehow gets into the bloodstream. How common is that that that's going to happen?

Dr. Madsen: It's not super common. It's more common in people who are older who have immune system problems. That's where we often see cases. But I mean, I've absolutely seen people who have come in with urinary tract infections, young, healthy females, who it works it way up to their kidneys. From there, you start to see the effects throughout their body.

And really, the effects we're looking for to call it sepsis are high temperature, so they're coming with a fever, they're breathing rapidly, their heart rate is going fast. We check blood work on them. Their white blood cell count, which is a sign of infection more throughout the body, is elevated. And then, sometimes in severe sepsis, their blood pressure even drops, just because that severe infection can cause the blood vessels to dilate. So that blood pressure's going to drop, and that's where it gets really serious.

Interviewer: So it could happen to anybody, even if you're healthy, more likely if you have a compromised immune system. Something to avoid, nonetheless. Are there ways to avoid getting sepsis?

Dr. Madsen: So really, the key to avoiding sepsis is to catch infections early. If you look at your arm, it looks like you have a skin infection. Let's say you have an area of a lot of redness, warmth. You touch it, you just say, "Wow, this is really hot here." You need to get on some antibiotics, because those are the things that can then progress to sepsis as that infection spreads. You're having urinary tract symptoms.

The times I see these cases of sepsis are people who might let it go for a couple of days, and then it works its way up. They start having back pain, fevers. That's when it becomes urosepsis, so starting from the urine and then that infection working its way through the body. Or pneumonia, the other common thing, people who are coughing a lot, high fevers. Things get much worse there. So if you can catch these things early, get on antibiotics, you can generally avoid that really severe form of the infection that we call sepsis.

Interviewer: All right, and if sepsis does kick in, what's the treatment for that?

Dr. Madsen: So sepsis, it requires hospitalization. So in these patients, and we've done a lot of studies in the ER, how do we best treat these patients, but the key is getting on top of it early. And what that means is getting IVs in, giving fluids. Just because people can be very dehydrated, they can have a lot of fluid loss from this. And then getting antibiotics early. I'm going to start antibiotics very early on these patients who come in who are septic and admit them to the hospital, often admitted for several days on IV antibiotics while trying to figure out exactly what caused the sepsis and making sure it's treated appropriately.

Interviewer: And why the long-term hospitalization on that? Why not just give antibiotics and let them treat it at home?

Dr. Madsen: Well, one of the challenges, they often need additional IV fluids, and they often need that IV form of antibiotics. Some of the IV forms are much stronger than what we could give at home, and so that's why they're in the hospital, monitoring them. This can be a life-threatening condition. I mean, some studies that were done on sepsis several years ago even showed that, you know, in these cases, they were finding 30% of patients with sepsis were dying. Maybe it's not that high now. I'm sure it's not now that we've improved our care, but this is a big deal. So these patients are often admitted and for several days.

Interviewer: So to me, it sounds like, if you experience some sort of an infection, especially some of the ones that you mentioned, that you should get on top of that and treat that so the sepsis doesn't ever become a problem. But then, if the symptoms start happening, you absolutely need to go to the hospital.

Dr. Madsen: Exactly. Once you get fevers, chills, you know, just things getting much worse, the back pain, like an infection in the kidney, just a cough that is just not getting better and you're bringing stuff up, lots of phlegm, yeah, get to the ER. This may be something more serious that requires some IV antibiotics.

Announcer: Want The Scope delivered straight to your inbox? Enter your email address at thescoperadio.com and click "Sign Me Up" for updates of our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.

Interviewer: What are emergency rooms doing about opioids? That's next on The Scope.

Announcer: This is From the Frontlines with emergency room physician, Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. And of course, by this point, most of us know that opioids are a major problem and it seems like taking that first one is what really lead you down that path. And for many people, they might have gotten them in the ER at one point. So I'm curious, Dr. Madsen, is that the case? Did you use to give out opioids for pain and has that changed?

Dr. Madsen: So I've absolutely given out opioids and we still do. I mean, there are cases where people need some kind of pain medication and, often, that's the only thing that's going to help them in the short term. But we've definitely seen the pendulum swing in the last few years. It used to be, in the ER we always talked about, "We're not treating pain adequately. We're not giving enough medication." And I think the response to that, 15, 20 years ago was to say, "Let's get more opioids. Let's prescribe more, let's give more IV medications."

Now, we've seen what's resulted from that. And it's not just the ER, it's primary care physicians, it's pain clinics, it's specialists. It's all across the spectrum of health care in the United States.

Interviewer: In the ER, was the opioid generally in pill form, or did you give it through IVs?

Dr. Madsen: We have often . . . and again, to say we don't do this, we do it because there is a role for opioids, and I think there's something we need to make sure we understand too is that there's a role for these medications people that have severe injury, long bone fractures, things like this, that's the only thing that's going to treat their pain adequately.

And so we do give at IV. There are IV forms of opioid medications like Morphine or Hydromorphone. And then there are pill forms as well that we can prescribe, hydrocodone, oxycodone, things like that. You've heard of Lortab, Norco, Percocet, all these sorts of brand names. So there are those two options that we use in the ER and that people use elsewhere as well.

Interviewer: So if I'm a patient, I find myself in the emergency department, and I'm told that my pain is such that you would recommend that I should have an opioid-based painkiller. Should I be nervous that I could possibly get addicted to it?

Dr. Madsen: I think the big issues with addiction come when we're taking medication not to treat the pain but often for the way it makes us feel. And if this is a new injury, if it's a serious injury, or if it's a serious issue like severe abdominal pain and that's the only thing that's going to control it, I think you need it. And I think you have to make sure you have some balance there and not just think, "Opioids are bad. I'm going to get addicted if I even have a touch of this medication." That's not the case.

So when people take it long term, they're taking it more for the way it makes them feel rather than, say, coming in for severe pain and I'm taking this because I need this pain in my abdomen treated right now because I've got a ruptured appendicitis or something like that going on.

Interviewer: So how have things changed in the ER?

Dr. Madsen: Yeah, so I think one of the biggest changes I've seen, so a couple of areas. Number one, we have a statewide database we can use and it's very useful. I can look up, if someone comes in and I can see have they gotten multiple prescriptions for opioids?

If they have and it's come from lots of different physicians, particularly lots of different ERs, I'll talk to that person and I'll express my concern, say, "We're seeing lots of different prescriptions from lots of different places. I'm concerned about the possibility of, maybe, addiction here. You need to go to one person, get this from one doctor so they can monitor what you're getting and make sure you're staying safe with these medications."

The second thing we've seen are just, like I talked about, decreased prescriptions for opioids for a lot of stuff that maybe we used to prescribe it for, for bumps and bruises and back pain because we wanted to make sure people's pain was taken care of. Now, I think it's more like saying, "Hey, try Ibuprofen. Ibuprofen, it's a great medication. Avoid opioids if at all possible."

Again, still there are cases where opioids are necessary. It's the only thing that's going to really adequately control someone's pain, but a lot of those kinds of gray zone areas. I think a lot more physicians are moving away from opioids altogether or are really limiting the number of opioids they're prescribing to those patients.

Interviewer: So this is a good first step, I would imagine. What else needs to be done?

Dr. Madsen: Well, I think we need to know a lot more about how we can better address pain and if there are other factors. Does anxiety really play into this, is something we studied in our ER. Patients who come in who are feeling very anxious, how much does that amplify the pain? If I address that anxiety, is that going to help with the treatment of pain?

Something else we're doing really new in our ER and one of the few places doing this is we have a physical therapist in our ER as well. So we're using our physical therapist to come in and see a lot of these people with back pain, work with them right there, get them set up with physical therapy to hopefully avoid the opioid prescription, to get them some treatment and say, "Hey, you don't need just to take pills for this. Here's some exercises, some strengthening, some stretching. It's going to give you a whole lot more relief than taking some sort of opioid."

Interviewer: So just like anything else, it's a useful tool. It's just that maybe we haven't been using it the best that we should up until this point?

Dr. Madsen: That's exactly right. I think the pendulum swung too far one direction and it's going back the other way. Hopefully, we can have some nice balance here and address this, what it really is, a nationwide epidemic.

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Interviewer: Flu season 2016-2017 update. That's next on The Scope.

Announcer: This is "From the Frontlines," with emergency room physician Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. And a lot of times, he's going to see things happening in the community before the rest of us really even hear about it. And from what I understand, it's a pretty bad year for the flu this year.

Dr. Madsen: It sure is, and, again, I'm speaking from my perspective in the ER where we see the sickest of the sick. But I have seen some incredibly sick people who have had the flu. These are people who have come in. I've seen them. I assume they some sort of just severe pneumonia, some sort of sepsis, where the infection from a bacteria has spread through their body. I'm not finding any source besides the flu. And these are individuals where I ask them afterward, I say to them, "Well, did you get the flu shot this year?" And they say, "Absolutely, I did."

So we're seeing a resistant strain out there. We're definitely seeing people who are getting very, very sick with this who we're admitting to the hospital and I'm seeing quite a few people. And as I talk to other ER doctors, as I talk to our pharmacists in the emergency department, they say that's been pretty much reflective of what we're seeing across the board right now.

Interviewer: All right. So the flu season, you just never quite know when it's going to hit, but you're saying it's hit.

Dr. Madsen: It has absolutely hit.

Interviewer: And if you got the flu shot, you're going to want to take some other precautions as well because it could be a strain that wasn't vaccinated for.

Dr. Madsen: That's exactly right. And I don't have all the data to note how many of these strains that we're seeing now are going to be prevented by the flu shot versus how many of these are not. Again, I'm seeing a lot of cases of people who had their flu shot who are getting very sick from the flu.

But don't assume because you had the flu shot you can just walk around anyone who's sick and walk away just fine. You've got to wash your hands. You've got to try and avoid contact with people who are sick, if you can, certainly if they're family members, just practice basic health hygiene. Try to stay well, but know that you may have the flu, even if you had the flu shot and you get sick.

Interviewer: So as an emergency room physician, how do you not get the flu then? Because, I mean, you're around all these really sick people with the flu.

Dr. Madsen: Yeah, it's a challenging thing. If people come to the ER with flu-like illnesses, in the triage area, they automatically put a mask on them because it's spread by droplets when they're coughing and sneezing. That's one thing you can certainly do at home. We wear masks in the room as well. Certainly hand washing, making sure we're doing that frequently. You know, it's basic hand washing and basic sanitation practices you'd do at home as well.

Interviewer: All right. And probably can't predict this. Do you think it's going to get worse?

Dr. Madsen: I do. I mean, given the increase that we've seen just in the last couple of weeks, I expect we're going to see this get worse over the next month And it could be a pretty significant flu season for us.

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Interviewer: Oh, the bells are jingling somewhere, there's a Santa Claus ho-ho-hoeing. It's Christmas time and in the emergency room, Dr. Troy Madsen celebrating the holidays, busy at work. This is a special episode of The Scope that we want to call "Christmas in the ER."

Announcer: This is From The Front Lines with emergency room physician, Dr. Troy Madsen on The Scope.

Interviewer: Welcome, Dr. Madsen.

Dr. Madsen: Thank you. I feel like this should be a song. Isn't there like a country song "Christmas in Dixie." Christmas in the ER kind of song.

Interviewer: Yeah.

Dr. Madsen: Kind of a melancholy song, you're working in the ER.

Interviewer: If we were to sing that song, what would we sing about, Dr. Madsen? What does Christmas look like in the ER?

Dr. Madsen: Well, I tell you, I'm going to be working Christmas morning at 7 a.m. I will be there to greet you if you come in the ER. As all the kids are opening their toys from Santa, I'm scheduled to work 7 a.m. Christmas Day. So Christmas in the ER, it's one of those days where, it's a lot like working on night shift when it's snowing and I find when you work those nights or if you work Christmas Day, basically, if anyone makes it into the ER, they usually have something seriously wrong with them.

It's not the kind of day that the person walks in that's had abdominal pain for two years or a person walks in with a splinter in their finger something like that. People put those things off. If people come in the ER on Christmas morning, you know that it's probably something you better take seriously because no one's going to leave their home or just go in Christmas Day unless it's something they're really concerned about.

Interviewer: So you know some serious stuff is going to come through the door. Is there anything typically you see on Christmas Day?

Dr. Madsen: In terms of typical stuff Christmas Day, once in a while you can, I know this sounds kind of funny but you can see some sorts of injuries from opening presents, and I know that sounds a little silly, but there are.

Interviewer: It does.

Dr. Madsen: One of the kind of the things that is notorious for potentially causing lacerations and injuries in opening gifts are kind of these clam shell plastic cases.

Interviewer: Oh, yeah, really?

Dr. Madsen: Yeah, have you tried to cut into one of those things? Like I've done it. I've even cut myself on it because you cut the thing open, then you get your hand in there to try and pry it open, and those edges it's thick plastic, it can kind of cut into your finger. I know it sounds a little silly but sometimes you do see stuff like that from people opening things.

Interviewer: Yeah, I didn't think of you using a knife to open boxes and stuff if you're not paying attention or and there's probably . . .

Dr. Madsen: Yeah, keep using knives, box cutters, things like that.

Interviewer: I shouldn't have been so quick to laugh, I apologize.

Dr. Madsen: It does sound so clichÈ that it's Christmas morning, you're opening gifts and you get injuries from that. But occasionally, you do see stuff like that. Later in the day, there's sometimes kind of the overeating stuff, people with some belly pain or just feeling a little bit uncomfortable. Again, maybe not such a big deal on Christmas but sometimes you get that. But like I said, it's really typically a very slow day in the ER and I'm probably going to jinx myself now by saying that because I'm working Christmas Day.

Interviewer: Here, quick, jingle these bells.

Dr. Madsen: Yeah, exactly.

Interviewer: Instead of knock on wood, you can jingle some bells.

Dr. Madsen: Yeah, exactly. But it is a day when people come to the ER, it's usually serious stuff and heart attacks, asthma problems, maybe a car accident as they're driving somewhere, things like that.

Interviewer: Do you guys celebrate Christmas at all in the ER? Is there a picture of Santa Claus up or Christmas cards around anywhere? I mean, do you decorate?

Dr. Madsen: Christmas in the ER there are usually some decorations up. I can't say that Santa has ever come to the ER. But usually, everyone will bring food in and kind of have a potluck dinner or potluck lunch in the ER, something like that.

Interviewer: That sounds kind of cool. I suppose there's a lot of camaraderie in there anyway and then when you're all working on a holiday even more so probably.

Dr. Madsen: Yeah, exactly. Like I said, it's usually slower days so you usually have some more time to get everyone together and have some food together. So it's not everyone's favorite place to be on on Christmas Day, but like you said, there's a lot of camaraderie there, people there. we're kind of in the same boat together just enjoying it together.

Interviewer: What do you bring to the potluck?

Dr. Madsen: What do I bring to the potluck?

Interviewer: Yeah, what's the Troy Madsen special Christmas dish?

Dr. Madsen: See, I am a horrible cook so usually anything I bring is going to be like already prepared food, usually a bag of chips or something like that.

Interviewer: Come on.

Dr. Madsen: I'm sorry to admit that but it's the truth. I don't really cook well, so it's usually what it is.

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Interviewer: When is a fever bad enough that you should go to the ER? We'll examine that next on The Scope.

Announcer: This is "From the Frontlines," with emergency room physician Dr. Troy Madsen, on The Scope. On The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. When is a fever bad enough to go to the ER? Dr. Madsen, shed some light on that for us.

Dr. Madsen: Yeah. You know, it's interesting you bring that question up because I've had people ask me even recently. They've said, "At what point is the fever just going to cook my brain and how high does it have to be to cook my brain"?

Interviewer: That can't happen. Right?

Dr. Madsen: I can't say I've ever seen it happen and I told them that.

Interviewer: Okay.

Dr. Madsen: And it's something that's out there. I remember hearing that too, like people saying, "Wow, you got to keep your fever down, or you're just going to fry your brain." I can't say I've seen that. So when I think of fever I don't think of the absolute number with the fever. We define a fever as being 100.5 degrees Fahrenheit or greater. So I think of fever more in terms of what are the symptoms that you're having or what kind of medical problems do you have.

This is a child, a young infant, less than, say, 12 weeks old, and they have a fever of 100.5 or greater, you got to go to the ER because there, we get concerned about a serious infection. If this is someone who has an immune system problem, who's on chemotherapy, or maybe has HIV, or something that's affecting their immune system, again, another reason to go to the ER. I'm not concerned about is it 105, is it 100.5, if they have a fever, they need to have testing done.

Interviewer: If they are in that particular group?

Dr. Madsen: Exactly.

Interviewer: Okay.

Dr. Madsen: If they have immune system problems, if they're very young, and then, of course, if they're very old, people who are very old also. It's interesting because very old people really don't get high fevers like someone in their 20s might. So in them, a fever or a temperature of 100.5, that's pretty significant. And again, potentially a sign of something going on that's very serious. Whereas the average person walking along, who's healthy, who has really no medical issues, maybe they have a cough, maybe they have a fever up to 102, even 103, in my mind, that's not so concerning.

So when I think of fever, I think of more the whole person, what kind of medical problems do they have. And then, beyond that, I think of "Okay, what else is going on?" If it's someone who has a fever, who says the light bothers my eyes, my neck is stiff, I'm confused, or someone is reporting to me that they're confused, then I think of meningitis. Fever with a really severe cough, or a cough that has been going on for a week, and won't go away, I think of pneumonia or a sinus infection. Certainly, fever is with your unary symptoms, back pain, we think about kidney infections and issues there.

So again, you're taking that whole picture. So I think the big take home point would be that I don't even own a thermometer at home. I don't check my own temperature. I know if I'm hot, or I'm cold, or family member is hot or cold. I've heard some pediatricians say, "Get rid of your thermometer. Just don't use it on your kids unless they're the very young kids less than 12 weeks old," Because there, you are again looking at the whole picture. It's not just the fever.

Is the child lethargic? Are they feeding well? Are they eating? Are they still urinating, meaning that they're still having adequate fluids in their body? You're looking at everything there in addition to the fever.

Interviewer: That's kind of a tough paradigm for me to wrap my head around because I think a lot of people are just driven by "Oh, 103 fever. That's burning up. That's a major problem." But it sounds like you're saying to take that as an indicator to maybe assess, are there some other issues going on and those other issues are actually the reasons why you'd probably go to the ER?

Dr. Madsen: That's exactly it. You could have 103 fever with kind of a run of the mill cold, and you could feel absolutely miserable, but it doesn't mean you have to rush to the ER.

Interviewer: Okay.

Dr. Madsen: And you can. If you're at all concerned, never hesitate to call your doctor. Never hesitate to go to an urgent care or an ER. But in your mind, I want to think of it as like, "Okay. This absolute temperature means you're sick or something less than temperature means you're not." Like I said, some people with 100.5-degree temperatures who have other problems, that's really serious. Whereas another person on 103-degree temperature, probably very well, just could be a viral infection, and it isn't that big a deal.

Interviewer: So this could be probably tough information for somebody to hear because I'm imagining if they're listening to this, they're concerned about somebody in their life with a fever. If they don't fall in one of those two groups, the very young, the very old, they're going to want to do something. But it sounds like what you're saying is a fever should only indicate that maybe you should look and see if there are other symptoms?

Dr. Madsen: That's exactly it.

Interviewer: Yeah.

Dr. Madsen: Yeah. I won't rush to get into the hospital based on a fever alone. Look at the whole picture. Look at all the symptoms. Look at how the person is acting. If they're acting fine, and they're eating well, and drinking well, and they're alert, and they're not confused, and they've got a temperature of 102, they're probably okay. You can give it some time. You can take some Tylenol, some ibuprofen, to bring the fever down and see how they're doing.

Announcer: We're your daily dose of health, sciences, conversation. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: Three symptoms that don't seem serious but could be. We'll talk about that next on The Scope.

Announcer: This is, From the Front Lines with emergency room physician Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Today, three symptoms that don't seem serious but could be. We're talking about signs that you might have a serious medical condition that a lot of people ignore because we're kind of numb to these things.

What are the big three? Let's start with number three. In no particular order, or is this in order?

Dr. Madsen: This is in no particular order at all.

Interviewer: Okay.

Dr. Madsen: Just the three things I thought of as we talked about this that people often don't take very seriously but when they come in sometimes we can find serious things going on.

First one on the list is headaches. And when we're talking about headaches, I think a lot of us are used to headaches. We work, we get tension headaches, sometimes we just don't feel quite right, a little nauseated. But I oftentimes find that people with headaches just feel like "I've just got to tough it out," just get through it and it will go away.

Interviewer: Right, it's a headache, everybody gets them.

Dr. Madsen: Exactly. And, sometimes headaches are a sign of something very serious going on. A lot of times, the red flags with headaches are, headaches that come on very suddenly, very severe, maybe make you feel more nauseated then maybe you've been with previous headaches, certainly if you're passing out because of headaches. Another interesting thing with headaches that's more serious is if it wakes you up in the morning, like you get a headache and you wake up and this headache is the thing that woke you up.

Interviewer: Okay.

Dr. Madsen: And that's often a sign of something going on in the brain, maybe a brain tumor or something like that that can be a more serious thing. So a reason to, certainly if it's a sudden onset severe headache, get to the ER, if it's a headache that's waking you up in the morning, something to talk to your doctor about, they may want you to come to the ER or get some sort of imaging of your brain to see what's going on there.

Interviewer: And it might not be a bad idea if you just kind of always have headaches to talk to your doctor about it because that's not a fun way to live.

Dr. Madsen: Yeah, you're exactly right. We do see cases like that, too, of people who come in the ER who say "I just get migraines all the time" and they could be on medication to prevent that, to prevent that ER visit and make their life much more comfortable.

Interviewer: All right, number two on three things that don't seem serious but could be.

Dr. Madsen: Yeah, so number two is back pain. And back pain is another one of these things you figure "Tough it out, I get pain in my back, maybe I was doing some lifting, something like that." But one of the really, really serious things with back pain is an aortic aneurysm, or a tear in the aorta. And classically with that, people will have pain that starts in their chest and goes though to their back and it's like a tearing pain, maybe it's down in their abdomen and they feel some pain in their back as well with that.

Interviewer: So upper or lower back it sounds like.

Dr. Madsen: Exactly.

Interviewer: Doesn't have to be just back from where the heart is.

Dr. Madsen: No it doesn't.

Interviewer: Even though it's a heart thing you're describing.

Dr. Madsen: Well it's related to the heart. The aorta is the main vessel that delivers blood from the heart to the body. So yeah, it is related to the heart. The heart is squeezing blood through there, so people sometimes just have just severe back pain with an aortic aneurysm or a tear in the aorta and that's something that's extremely serious, you've got to get to the ER, get that checked out. And typically with that, they just have sudden onset severe pain. That's how they describe it. Just a sudden onset pain feels like a tearing or a ripping sort of pain.

You know with back pain as well, you can have issues like cancer, tumors in the spine, things there that will cause you pain that's often more severe when you're lying down or certain positions. It's a little more rare, but that would be something to see your doctor about. They could get an x-ray of your back, sometimes they'll get an MRI to take a look there and see what's going on.

Interviewer: So if it's something you've lived with for a while, there again, go see a physician because why should you live with that. If it's something that comes on very suddenly, for no real apparent reason, that's the trip to the ER time.

Dr. Madsen: Exactly.

Interviewer: All right. Number one on the list of three symptoms that don't seem serious but could be.

Dr. Madsen: And number one is abdominal pain. And we see lots and lots and lots of people with abdominal pain, and we see lots of people with abdominal pain who don't have anything wrong. But then we see people with abdominal pain who come in and say "I've had this pain in the right lower side of my abdomen for five days now. I just figured it was gas and it would go away." We get a CT scan and they have a ruptured appendicitis. And that's just not good.

So there are things in the abdomen that can go very wrong, and it generally happens over time. Typically in the abdomen, it's not something that's going to happen all of the sudden, but if you're having abdominal pain and it's not going away after a few hours, it's progressing, especially on the right side of your abdomen. If you're a typical young, healthy person, the right lower side is your appendix, the right upper side is your gall bladder.

Those are the most common things I see in young healthy people who are just like "I've had abdominal pain before. This will go away." They come in, they have a ruptured appendicitis, or they have a very serious case of cholecystitis, which is an infection of the gall bladder, and they have to go to the operating room to get these things repaired, which they would otherwise but often it's a much more complex case because the infection there is so advanced.

Interviewer: So it sounds like the first two, sudden symptoms. The third one, symptoms that have lasted for a while.

Dr. Madsen: Exactly. Things that came on more gradually and then progressed but people just keep thinking "This will go away" and it's not going away.

Interviewer: That's for the abdominal pain. How many days, if I kind of have a consistent abdominal thing going on, what should my line be, where I'm like "I better go see somebody"? Five days? Is that it, or sooner than that?

Dr. Madsen: I would do sooner than that. With the appendix, with the gallbladder, most things if you got a little bit of food poisoning or some gas in your stomach it's going to get better within six hours. If it's going on beyond that, if you're getting more toward 12 hours with this sort of thing, that's definitely I think a reason to at least see your doctor about it.

Interviewer: And I think it's also interesting too because I know a lot of people from some previous podcasts talk about very sudden abdominal pain like waking up in the middle of the night, sudden abdominal pain. From what you just told me, that doesn't sound like necessarily the thing to worry about. It's if it continues over time.

Dr. Madsen: Well, and again it becomes challenging because I mention that thing to you about the aortic aneurysm, like the back pain, that's also in the stomach that is a sudden thing, so it comes a little bit more challenging.

Interviewer: How do I know if something happens suddenly if I should be concerned? I mean, how do I parse this out?

Dr. Madsen: I think you have to base it on the severity of the pain, how it compares to your previous pain. But these are things where people kind of ease into it, it's like "Oh this isn't so bad. I've got a little pain in the right side of my abdomen. I'm used to having a little bit of abdominal pain." But then they gradually get worse and worse. Maybe some of these other serious things in the abdomen, they come on suddenly, and they're severe.

And so, you base it on the severity, and then those things that aren't so severe, you base it on well, what's it been doing over time, has it just been gradually getting worse, that's a sign often of something more serious.

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Interviewer: You or somebody you know suddenly seems very confused. Confusion as a symptom, what could that possibly mean?

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency physician at University of Utah Healthcare. Dr. Madsen, as far as symptoms go, if somebody seems confused all of a sudden, whether it is myself or somebody I'm with, what could be the underlying cause of that? For example, with elderly people I know a urinary tract infection can cause confusion, which blew me away.

Dr. Madsen: Right. You know, the average person, and we'll try not to get into the elderly people too much here because that's . . . anything, just a urinary tract infection, like you said, can cause issues.

Let's say we've got the average person out there. Let's say it's a 40-year-old male who normally, has no health issues and just suddenly seems confused. This can be very challenging but for me this is where vital signs are vital. I'm looking at the vital signs because that's what is really going to point me in one direction or another.

First of all, I talk to the person. Yeah, let's say they just seem like they're not quite there. They're not answering questions appropriately. Of course I want to know, did they have anything happen? Were they injured? Did they have a head injury? Are they using any drugs or medications? Anything like that, but in looking at the vital signs that's going to push me in one direction or another.

If they have a fever, I'm thinking possibly meningitis. This person might need a spinal tap or a lumbar puncture to look for some kind of infection around their brain that's causing this. It could be another infection maybe like pneumonia, less likely to make someone just suddenly confused who's normally health, but a possibility.

I'll look at their heart rate. If their heart rate's really fast, and this is something I see quite commonly, heart rate up above 150, up to 200, they might be having an abnormal heart rhythm, something we have to treat either with medication or with a shock to the heart to get that back in a normal rhythm because that really rapid heart rate can make them confused. They're not getting as much blood to their brain.

Maybe their blood pressure is low, and if the blood pressure is low I'm thinking about maybe they're bleeding somewhere. I've see people who have had some kind of internal bleeding either in their stomach or in their intestines that causes their blood pressure to drop down suddenly. They seem confused and weak. That's a very serious thing but I have absolutely seen that happen in young people. Very serious cases of bleeding in someone who maybe is taking a lot of ibuprofen for some pain and it causes some stomach irritation and bleeding.

So those are the primary things I'm looking at, and then I might look at their oxygen level as well. I have seen cases of people with low oxygen levels who have had suddenly a blood clot in the lungs and it goes to the lungs, it causes their oxygen level to drop, their heart rate's up. That causes confusion as well.

For me, again, it's one of these things where it could be any of a number of things, but if you're with someone who is normally healthy, really doesn't have a lot of health issues and suddenly they're confused, that's someone absolutely I would get to the ER and then as an ER doctor there I'm going to be going one direction or another based on what's happened to them prior to that and also really looking at those vital signs to see, okay, is there one direction I need to go here either with infection or with the heart or something in the lungs, something that's causing this confusion to happen.

Interviewer: So it sounds like the cause of confusion is just the brain's not getting enough of something.

Dr. Madsen: Exactly.

Interviewer: Whether that be oxygen, blood. What else would it need?

Dr. Madsen: Well, the blood is delivering the oxygen so typically it's something that's decreasing the blood flow there. Maybe there's just not enough oxygen getting in the body. Certainly young people it's less common but you have to think about strokes or bleeding in the brain.

I have occasionally seen cases of people who seem confused but it's because they're just not speaking correctly. Either they're not pronouncing words correctly or they can think of the right words in their brain but they can't get the words out. That's from either some sort of a stroke, from something breaking off and causing decreased blood flow to the brain or actual bleeding in the brain that's affecting that. Again, these are all things that are emergent issues.

Interviewer: Yeah, sudden confusion is not a good thing, I'm gathering.

Dr. Madsen: Not a good thing.

Interviewer: Go to the ER.

Dr. Madsen: It's not, and it could be any of a number of things, and yes, you should go to the ER.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: August 2, 2019
originally published: June 17, 2016

Scot: Is it bad enough to go to the emergency room, or isn't it?
Find out now. This is ER or Not on The Scope. Time for another addition of ER or Not with Dr. Troy Madsen, Emergency Medicine at University of Utah Health Care. Here's the scenario. Decide if you need to go and then we'll get the answer from Dr. Madsen. I cut myself, do I need stitches? ER or not?

Dr. Troy Madsen: So cuts are tough. It's one of those things that I always think to myself, "Man, if I were out traveling and I had to go to the ER for a cut for stitches..." You know, it's not a fun situation to be in because usually you're waiting for three or four hours to get in. You know it's really a great question, "Do I really need stitches on this?"
If you look at the wound and you look at the cut and the edges are gaping, or they're not together, then that's a sign you need stitches. The big thing stitches do is they just pull the wound together. They hold it together to make sure that it heals up nicely.
It becomes a much bigger concern if it involves the face. There we worry much more about cosmetic outcomes and making sure things look okay. If the wound is open, if you're seeing tissue coming out of it, maybe things you know that look a little bit deeper than the skin, those are all signs that you probably are going to need stitches.
Otherwise, if that's not the case, you can try a bandage on it at home. There are some things I've seen at the store; actually, liquid bandages they call them. It's kind of similar to some stuff we use in the ER. It works pretty well for holding these lacerations and keeping dirt and things like that getting in there if it is something more minor that doesn't need stitches.

Scot: Is this an Instacare thing maybe?

Dr. Troy Madsen: Sure. Absolutely. Instacare is the perfect place for this kind of thing. A great place you can usually get in a little more quickly than the ER. Get that sewn up. If there are a lot of big concerns with bleeding, a lot of blood coming out of that or if you are having trouble feeling in your hand... Let's say you've got a cut down further on your wrist and you lost sensation. That's a reason to come to the ER because we might need to get a hand specialist to see you. Urgent Cares are a perfect place for these things otherwise.

Announcer: We're your daily dose of science. Conversation. Medicine. This is The Scope, University of Utah Health Sciences Radio.