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1. Why are some shots given in the arm and others are, um, not?

Great question! The location of your shot depends on a couple of things. First, different shots have to be injected into different anatomic structures. For example: the tetanus shot is best absorbed when injected into a muscle. In adults this is easily accessed in the outer arm, while in munchkins we use the outer thigh. These are both bigger, “meatier” parts of the body where they are easily absorbed and less likely to hurt.

Other injections, like a TB test, must be injected just under the skin so we can see it. For this we generally use the front of a forearm, where the skin is much thinner and easier to access. Still yet, a lot of medicines have to be directly injected into a vein, and for this we have to find a blood vessel close enough to the skin to feel and get a needle into in order to give it. This is what people are talking about when they say they have “rolling veins” or that they’re a “hard stick." Most of the time we can find a vein in the back of a hand or the inside bend of your elbow, but sometimes we have to get creative and find one in a foot or the top of a baby’s head to get good access. In absolute dire circumstances we can attempt to get to your blood stream by getting into the middle of a bone, called “interosseous” access, but we save that for last ditch efforts.

Secondly, the volume of medicine helps us decide where to give a shot. For example some shots, like a steroid, testosterone, or fertility injection, require a bigger amount of fluid that your arm just can't handle. For this reason we have to go . . . you guessed it . . . right in the rump! The bum is a bigger muscle that can hold more medication, and due to its bigger (and generally, "fluffier") space, it typically doesn't hurt as much.

With all of this being said I”ll take this opportunity to shamelessly beg everyone to get a flu shot. If you have questions or concerns about getting your flu shot (there are LOTS of rumors floating around about this vaccine in particular) then please ask your doc! Also keep in mind that any injection carries a risk of infection, bleeding, and reaction to the medication. It’s not uncommon to get some tenderness and redness at the site of the injection. This does not mean you have an allergy. Ask your doc for more details!

2. How do you know when to go to the emergency room and when to go to urgent care?

This is a fantastic question that I hear frequently. It can be confusing and sometimes scary when trying to decide if you need emergency treatment, and the answer sometimes changes. For instance, if you have a sudden change in health Monday through Friday during general office hours (usually 8 a.m. to 5 p.m.), a good rule of thumb is to call your primary care provider's office and ask if they have a recommendation. Often times they will be able to direct you to either their office if it's something they can treat in an outpatient office setting, or give you better instructions on whether an urgent care can handle your concern. Despite our best efforts to make the ER a better experience, it often is associated with expensive visits, long wait times, a shortage of healthcare employees and exposure to dangerous germs. For these reasons we docs try really hard to keep people out of the ER unless they truly need emergency care.

Please keep in mind that the ER is not a great place for addressing chronic issues like low back pain, high cholesterol and blood pressure and getting medications refilled. The ER staff probably doesn't know you well and these issues are best left to your primary care team (which means you may need to plan ahead and request a refill when you get down to your last few days of medicines-especially pain meds). For a good review of what types of symptoms are appropriate for an urgent care center versus the emergency department keep reading!

 Emergency department:

• Chest pain or difficulty breathing

• Weakness/numbness on one side

• Slurred speech

• Fainting/change in mental state

• Serious burns

• Head or eye injury

• Concussion/confusion

• Broken bones and dislocated joints

• Seizures

• Severe cuts that may require stitches

• Facial lacerations

• Vaginal bleeding with pregnancy

• Trauma (car accident, fall from a distance greater than standing, etc.)

Urgent care:

 • Fever

• Vomiting

• Diarrhea

• Abdominal pain (this one can be tricky and sometimes requires emergency visits)

• Typical migraine headaches in people with established migraines

• Dehydration

• Common cold and flu-like symptoms

• Sprains and strains and back pain

• Small cuts that may require stitches

• Pain with urination

• Eye redness and itching

3. Can you really pick up that many germs just by handling a doorknob or a railing? Couldn’t we become a little too sensitive about those things?

The answers here are yes and “maybe." It is true that tons of germs can live on a single door handle. How well those germs are passed on to humans depend on how large the handle is (lever versus a traditional round knob), what it’s made out of (metal versus wood), the humidity in the air surrounding the handle, and where the handle exists (on the inside of a closet versus the outside of a public bathroom). On average, the flu virus can live on a surface for just over 24 hours. If you touch that surface and then touch your face you increase your risk of getting the flu. You also run the risk of accidentally giving it to someone else if you touch them as well.

This is more or less the story for most major germs, although how long they live on a surface can vary. For this reason it is important to adequately disinfect surfaces that people touch on a regular basis (door handles, your computer mouse, the door to your refrigerator and your cell phone especially). If you go into a medical office or a hospital you’ll probably notice a ridiculous number of bleach wipes, soap, and hand sanitizer everywhere you go. This is to ensure that we’re not inadvertently transferring harmful germs from one person to another. This helps us prevent the spread of sickness.

The second part of this question gets a little tricky. It is true that since the invention of better cleaning practices we have seen a significant increase in the amount of allergies and asthma in our population. One thought behind this is that when we’re not exposed to as many harmful agents, like bacteria and viruses, our immune system gets “bored” and starts reacting to random things like pet dander, trees and grasses, and different foods. Yet another thought is that it’s not so much that we are living in cleaner environments as much as we’re no longer being exposed to certain “good” bacteria that keep our immune systems appropriately entertained.

For example: Does a child who lives on a farm and is constantly exposed to dirt (representing germs that humans have been exposed to for centuries and can have some benefits) have a lesser chance of having allergies and asthma than a kiddo from the city (where there is no dirt and thus the immune system is less active), even if they both have super-clean homes? The answer is “maybe."

The old quote “just rub some dirt in it” may not be that bad of advice. While we still strongly recommend that people DO clean their homes and work places to prevent the overgrowth and spread of bad, infection-causing, life-threatening germs there also may be some benefit to being exposed to natural bacteria (i.e.: dirt and the outside world) to prevent allergies and asthma symptoms. All the more indication to give your kids some good ol’ cleaning chores and then make them go play outside!

4. I went to the fair and I was told to wash my hands immediately after I touched an animal. What is the danger?

This question is closely related to the above question No. 3.

Animals can carry a wide variety of germs that are different than ones typically carried by humans. Given this, you run the risk of catching a bacterial or viral illness that may be hard to fight in a human since it’s usually found in animals.

Swine flu originally was quite common in pigs until it mutated and was able to be picked up by humans. When humans first started getting sick with this strain of flu it was really hard to treat and caused a lot of problems because our immune systems had never seen it and had no idea how to fight it (think the movie "Contagion"). The same idea goes for the animals at the fair. In addition, the animals at the fair are typically around dust and hay that can trigger allergies in some people, as well as urine and feces that carry their own germs.

Just give your hands a good wash after your visit to get rid of these germs. And have no fear, there’s no reason to get rid of your favorite Fluffy and Rover. As a whole, people who are generally healthy have no trouble with your average pets, since you have a functioning immune system. So bring on the puppy kisses!

5. I have one eye that seems droopy. What causes that? Is there a fix?

The term we use for a droopy eyelid is “ptosis."

It can occur in one or both eyes, and can be either congenital (you were born with it) or acquired (it happened later in life). Children with ptosis often times will tip their heads back or raise their eye-brows frequently to compensate for the droopy eyelid and to allow for better vision. This condition really needs evaluation by your doctor to rule out dangerous causes like a brain tumor or a stroke.

Most times it is caused by a problem with the nerve that goes to the muscle that lifts your eyelid (the levator palberae superioris muscle-for you anatomy nerds). Over time this condition can get worse and cause head, neck, and vision troubles, including a “lazy eye” or “cross eyes."

In adults ptosis is most commonly caused by aging or an eye injury. Regardless of the age of the patient, this condition needs to be evaluated. Based on the severity of the “droop” your eye doctor can do a small surgery to help the eye muscles work better and improve the condition. The goal in this surgery is to maintain or restore vision and prevent the droop from returning by lifting the muscle.

The surgery is commonly done in your eye doctor’s office using a local anesthesia (meaning we don’t have to put you “under”). Sometimes we use drops that numb the eye for this procedure as well.

 6. Why does it take so long to get results from blood tests? Are the technicians just backed up? Or are there other complications?

I bet I ask myself this questions 10 times a day at the hospital. When it comes to sick patients I want answers and I want them NOW.

Unfortunately, getting lab results can be a time-intensive effort. First, the patient has to get the blood drawn. In the hospital that means a phlebotomist has to come to the patient’s room and draw the blood. Then it has to be delivered to the lab. It’s not very practical to go back and forth between the lab and each patient’s room, so usually one phlebotomist will collect multiple patients’ samples and take them all to the lab at the same time.

Once the blood gets to the lab any number of tests has to be run on it, depending on what test result is ordered. This can mean putting some of the sample on some agar (basically a Jell-O that’s used for growing specific bacterias) and waiting a few days to see what grows on it. This could also mean mixing the sample with certain chemicals to see if it has a certain reaction.

Sometimes the lab has to put the blood in different machines that spin the blood or divide out certain parts of the blood in order to get the test we want. All of this can take a fair amount of time.

Additionally, some tests can only be run in certain labs and so the sample has to be shipped to another location (around Sioux City it seems to be we send most labs to Mayo Clinic, which is a bit of a drive). The shipping time can add up, plus these “send out” labs tend to be more intensive and can take a while to run as well.

If it’s a "send out" lab, or if your outpatient office can’t run the lab “in house” and has to send it to the hospital to be analyzed, then the wait gets longer because the results have to be sent back to your doctor’s office and interpreted by your doc. All of these things can contribute to a longer “wait time” in getting your results.

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