High on Bath Salts?

They are not the bath salts you use in your bath.

These "Bath Salts," are a new and very popular designer drug that the Drug Enforcement Agency (DEA) is hoping to make illegal in the U.S. In September of this year, the DEA invoked its emergency scheduling authority to make them a controlled substance, and its sale has been banned in 35 states, as the National Poison Control Center has reported more and more calls about this drug. In an article written by Ann Bryant of Maine's Sun Journal, Deputy Chief of Farmington's Police Department Shan Cote reported that 303 calls for bath salts exposure were made to poison control centers in 2010, and that more than 5,000 calls have been made so far in 2011.

What are bath salts?

These bath salts are synthetic stimulant/hallucinogens similar to ecstasy and PCP. They were initially made in France in the 1920's , seen in Europe in the late 2000's, and here in the U.S. during the last few years. It has a number of harmless-sounding names such as Ivory Wave, Purple Wave, Oblivion Bath, Vanilla Sky, Bliss, and Snow White. Their proper names are mephedrone, MDPV (methylenedioxypyrovalerone), and methylone. They are found in mini-marts, smoke shops, and often appear as small bags of crystal white or brown powder. In the past they could be found in convenience stores and head shops next to the 5 Hour Energy products.

Why the name?

They have been marketed at "plant food" and "bath salts" and labeled as "not for human consumption," to avoid being made illegal. While it is banned in many states, it will take a federal law labeling them as a schedule 1 drug ( no medicinal value with a high potential for abuse) to officially declare bath salts illegal. For now, in some areas a small envelope of the drug can cost $25 to $50.

Are bath salts addictive? How are they taken?

It's not currently known if they are addictive but like other stimulants they are expected to cause cravings. It is snorted, injected, and mixed with food and drinks.

What does bath salts intoxication look & feel like?

One's blood pressure and pulse will rise. While high you may feel euphoria, confidence, experience increased alertness, focus, and productivity. The downside consists of depression, anxiety, aggression, delusions of superhuman strength, and a rise in body temperature causing many to remove their clothing. The downside continues with as one can become agitated, paranoid, experiencing hallucinations and suicidal thoughts. Users have been reported to be unaware of a broken limb, and to have damaged ambulances and hospital rooms.

Suicidality has been known to be ongoing after the stimulatory effects have dissipated, and suicides were reported days after use in the media.

Bath salts are part of a trend of drugs designed and named such that they are legal and thus easily obtained for long periods before detected by law enforcement. We must remain vigilant.

Holiday Heart Syndrome: An Unwanted Gift

Now that we are in the throes of the holiday season, I must warn you of Holiday Heart Syndrome, brought on by drinking too much wine, too many beers, and consuming too much sodium. You say you don't have heart disease? It doesn't matter. You can still get it.

What is it?

Holiday Heart Syndrome is not just stress. It is a real condition in which the heart is more vulnerable to disturbances of the heart's normal rhythm. It is a rapid, irregular rhythm your heart can enter when you drink too much alcohol. Most commonly the heart goes into ATRIAL FIBRILLATION, a rhythm characterized by the quivering of the heart's upper chambers called the atria. The atria normally contract in a regular fashion, squeezing blood efficiently into the lower chambers of the heart called the ventricles which send blood to the body. When the atria are merely quivering, that efficiency is lost, meaning not all of the blood will enter the ventricles but will sit in the atria. Blood that is not in motion can thicken, forming lumps called clots which can block circulation, causing strokes and heart attacks, and the loss of fingers or toes based on where they lodge themselves in the body's blood vessels. Other rhythm disturbances the heart can enter include atrial flutter, and premature beats. Premature beats can come from the lower as well as the upper chambers of the heart.

What causes it?

We are not entirely certain of the cause, but it tends to happen when a person has consumed too much alcohol, is stressed and/or is dehydrated. There are theories that it is caused by a rise in one's epinephrine or norepinephrine (adrenaline or noradrenaline) levels. These stress hormones increase heart rate.

Who is at risk?

People who usually have no history of heart disease often experience it.

What are the symptoms of Holiday Heart Syndrome?

The symptoms are caused by the heart entering a rapid and irregular rhythm. This can cause the sensation of palpitations which cause a fluttering in the chest due to the heart racing, pounding, or skipping beats. You may also feel chest tightness, shortness of breath, dizziness, or like you will faint.

How is it treated?

Go the the emergency room. You might need intravenous fluids, medication to slow the heart rate, and monitoring of your heart's rhythm. Usually the symptoms resolve when the offending agent or condition is no longer present in the system. Bring a list of all your medications. Know your personal and family medical history. Be honest when telling of any drugs or alcohol consumed. If you are without heart disease, the symptoms usually resolve within 24 hours and you will be cleared to return home. If there is concern for undiagnosed heart disease, you may need to be admitted to the hospital for additional evaluation and treatment. Underlying heart disease, combined with the symptoms of chest tightness and shortness of breath means a greater chance you may be having a heart attack.

Young Girl with Promising Future Dead over $20.

Kamisha Richards (left), 22 years old, lent $20 to her lifelong friend, sister of her boyfriend, Kayla Henriques (right), 18, for diapers. Kamisha found out Kayla spent it on something else. She confronted Kayla on Facebook with an embarrassing statement. Kayla allegedly said, "Dnt try to expose me mama, but I'm not tha type to thug it out ova facebook ima c u wen u get frm wrk."


"I'm a have the last laugh," said Kamisha.
Kamisha had her last breath later that night.
She was pronounced dead at the Brookdale Hospital.
I think of how I could have had that task....

What happened?
After the Facebook feud, Kamisha went to Kayla's apt and confronted her in her kitchen. The argument ended with Kayla stabbing Kamisha in the chest with a steak knife. Kamisha was 22, with a degree in criminal justice, and worked as a security guard with plans for law school. Kayla is 18, she's a junior in high school, and is the mother of an 11 month old boy.

Controlling your anger can save your own life.

There are 3 ways of dealing with anger:
1. Expression
2. Suppression
3. Calming.

Expression of anger is healthy. The way in which you express it key. Declaring and defending your boundaries without hurting others is difficult. How can one do this? Don't start with the word "you," when expressing unhappiness with a person's behavior. Tell the person how you feel. In this case, Kamisha could have said, " I felt used when I heard that the money was used for something else." Tell that person what you need from them. "I need to know that you will pay me back as soon as you can."
Do not shame that person with hopes the embarrassment will make them come correct. It too often creates more anger. Instead of being shamed into doing right, the person can become defensive, and hurt you even more to deflect that shame, especially when you publicly shame them. This is what happened here. Kamisha's attempt at shame escalated the anger in both of them.

Regardless of what is said, remember: Respect for yourself and the other person must be maintained. Respect prevents threats.

Suppressing anger is when a person holds it inside, and tries to ignore it. This is a popular way to deal with anger. We try to direct that energy in a positive direction. That's not always effective. Energy that isn't released needs somewhere to go. It turns inward and does its damage there, causing conditions like depression, and high blood pressure.
Anger that is not expressed can come out in other destructive ways. It may show up as a nasty attitude, a poor outlook on life, endless criticism, and poor relationship skills. This may irritate others, but they can get away from you. You cannot escape your thoughts and views on your life. Your feelings determine how you experience life. This is why your negativity hurts you the most.
Kamisha could possibly still be here if she had tried CALMING.
Calming can be as simple as telling yourself to, "calm down, take it easy." Taking slow deep breaths with closed eyes, using your diaphragm not your chest and repeating those calming words lowers the heart rate and blood pressure.
After this exercise, think.
What do you want from this person? Do you care if you risk your friendship? How could this person hurt you? Is the money worth it? Is being right worth it? Lastly, ask yourself, "Why are you friends?"
Now speak.
Then listen.
Back to this tragedy. Kayla may have truly felt bad about having to use that money for something else, and intended to pay Kamisha back ASAP. If Kamisha had calmly asked questions, she could have found out this to be the case. Asking questions during an argument slows its pace, and brings focus back to the real issue.

These girls were lifelong friends. Kamisha, who seemed to have made better life decisions over a period of years, paid for a few hours of poor anger management with her life.
When people imagine anger management, they think of protecting others. Controlling your anger can save your life.

Be safe. Be successful.
Rapp, M.D.

Serena Williams Undergoes Emegency Surgery for Pulmonary Embolus

What are pulmonary emboli (PE's)? "Pulmonary embolus" literally means "lung clots." They are blood clots in the lung. These are often formed in the calves or thighs, after long periods of immobilization, broken long bones like thigh and leg bones, and during high estrogen states like pregnancy and cancer. While in the legs and thighs they are called DVT's (deep venous thrombi). They can migrate through the heart to the lungs and if large enough, can cut off circulation and breathing altogether. When this happens, a person can suddenly collapse and die. Those who survive PE's often present to the ER complaining of shortness of breath, chest pain, heaviness, or tightness, or coughing up blood. They may or may not have accompanying leg pain or swelling. They may show a rapid rate of breathing, low oxygenation, and a high heart rate. Diagnosis is confirmed with CT scan of the chest, and a V/Q or ventilation /perfusion scan. Treatment requires blood thinners (anticoagulants) like Heparin, Lovenox, and Coumadin (warfarin) to help dissolve the clot.
Things that put us at risk include frequent and long plane/car trips without enough breaks to walk, stretch and massage the legs, especially when dehydrated, obesity, cancer, smoking, birth control pills, and smoking while taking birth control pills.
So remember, control your weight, avoid smoking, get cancer screenings as appropriate, stay well hydrated, and take frequent breaks to walk during long trips. While taking birth control, keep the symptoms mentioned in mind, so you know when to seek medical attention.

September is Gynecological/Ovarian Cancer Month

In honor of Gynecological Cancer Awareness Month, let us first discuss the most deadly one, ovarian cancer. According to the Women's Cancer Network, ovarian cancer is the most deadly cancer of the female reproductive system. It is the 4th leading cause of cancer death of women in the U.S., and is second only to uterine cancer in prevalence. According to the American Cancer Society, 22,430 women will be told they have ovarian cancer this year .
One in 57 women will get ovarian cancer, and it usually happens in women over the age of 50. It is 50% more prevalent in white women. The adjusted mortality rate is highest among white women followed by Hawaiian women, and lastly black women.

Why is ovarian cancer so deadly?
Due to it's position in the abdominal cavity, early detection is difficult, showing no or mild symptoms until it is at an advanced stage where the 5 year survival rate can be as low as 11 percent. Early detection could mean a 5 year survival rate as high as 92 percent.

What are the risk factors for ovarian cancer?

According to The Johns Hopkins University, ovarian cancer occurs more frequently with the following:

1. History of ovarian cancer in your immediate family
2. Age over 50
3. Fertility drug use
4. High fat diet
5. White race
6. Never having children
7. Hormone replacement therapy
8. History of breast cancer diagnosed before age 50
9. Being of Ashkenazi Jewish descent

Having immediate family members who have had ovarian cancer raises your risk of having ovarian cancer in your 40's rather than your 50's.

What are the symptoms of ovarian cancer?
It can present with nonspecific symptoms, meaning the same symptoms caused by many other conditions. However, certain symptoms are seen more frequently among women with ovarian cancer:

1. Bloating
2. Pelvic or abdominal pain
3. Difficulty eating, feeling full quickly
4. Vaginal bleeding
5. Urinary urgency or frequency

These symptoms tend to be persistent, and occur daily for 2-3 weeks and require a doctor's evaluation if they last that long. Other less specific symptoms include:

1. Fatigue
2. Indigestion
3. Back pain
4. Painful intercourse
5. Constipation
6. Menstrual irregularities.

How is a person screened for ovarian cancer?

1. Pelvic examination and Pap smear
2. Transvaginal ultrasound
3. Testing for the protein CA-125, elevated in 80% of women with ovarian cancer
4. Culdocentesis- a sampling of pelvic fluid found in a "cul de sac" between the uterus and the rectum.

Don't be alarmed if your doctor says you don't need the CA-125 test or an ultrasound to detect ovarian cancer early. According to the U.S. Preventive Services Taskforce, it is meant for women who have inherited a BRCA (breast cancer) gene change and who still have their ovaries. They get tested annually starting at age 35.


Once ovarian cancer is diagnosed, you have 3 treatment options. The first is surgical removal of the ovaries. The second is chemotherapy, and the third is radiation. The form of treatment is based on the stage of the cancer, the type of cancer cells present, and the patient's age and physical condition.

Can certain things be protective against ovarian cancer?
The Johns Hopkins University says there are no simple preventive measures to take that significantly reduce one's risk of ovarian cancer. However, it is said that the following are associated with a lower risk of cancer:

1. Breastfeeding
2. Hysterectomy
3. Birth control pills
4. Tubal Ligation


What can you do to protect yourself?
1. Get regular pelvic exams
2. Know your family history
3. Reduce the amount of fat in your diet.

The National Cancer Institute advises increasing one's fruit, vegetable, and whole grain intake, lowering fat consumption to <30% of calories, maintaining a healthy weight, minimizing one's intake of cured, pickled, and smoked foods, and only drinking alcohol in moderation if at all.
So many conditions, and ER visits, can be prevented by following this advice.

Be safe, be successful,
Rapp, M.D.

Diverticulitis and The American Diet

I diagnosed yet another patient with diverticulitis today. "What causes it?" he asked. My answer was...

"The low fiber American diet."

What is diverticulitis?
Diverticulitis means inflammation of diverticula. Just having diverticula means you have "Diverticulosis." Diverticula are herniations or outpouchings, marble-sized on average, that form at weak points in our intestines, usually due to excessive force needed to push waste through the digestive system. It's like the herniae that form in our abdominal walls and groin area from repeated, improper heavy lifting. Eighty to eighty-five percent of patients with diverticulosis have no symptoms.

What causes diverticulitis?
In the past, it was thought that nuts, seeds, popcorn and corn caused diverticulitis when caught in the diverticula. According to the Mayo Clinic, research has found that these foods are not the culprits. Another school of thought is that the small openings to the diverticula can trap stool, reducing the blood supply, causing inflammation.

What are the risk factors?
While the cause of diverticulitis has not been agreed upon, the risk factors are straightforward.
They are:
1. Aging-Emedicine says the prevalence before age 40 is less than 5%. According to Drs. M. Schein and R. Paladugn of Cornell University's Surgical Department, it's prevalence is 30% by age 60 and 65% by age 85. The Mayo Clinic suggests that with age may come a decrease in the strength and elasticity of the the bowel wall after age 40.
2. Low fiber diet- Diverticulitis is rare in countries where people eat high fiber diets which soften stool, but it is common in industrialized countries where processed food are more available. As the Japanese adopted western eating habits, the prevalence of diverticulitis has also risen. Diverticulitis has grown in prevalence since the invention of rolling mills that reduce the fiber content of grains and flour.
3. Inadequate exercise- A sedentary lifestyle has been associated with a higher risk of diverticulitis. Why the connection exists is not clear, but exercise helps control constipation, a risk factor for diverticulosis.
4. Obesity-The Mayo Clinic says being seriously overweight is also a risk factor for diverticulitis and diverticular bleeding.

What are the Symptoms of Diverticulitis?
Usually the pain is of sudden onset in the lower left side of the abdomen. Sometimes the pain may come on slowly and worsen over the next several days. The pain may wax and wane, your bowel habits can change, causing diarrhea or constipation. You may experience nausea, vomiting, and even fever. Even less common but possible symptoms or signs are a bloated feeling and rectal bleeding.

What's the Worst that Can Happen?
1. Peritonitis- If the inflammation or infection weakens the pouch wall enough, a hole will form, releasing stool into the abdominal cavity, inflaming and infecting it's lining, the peritoneum. This condition is called "Peritonitis," an emergent condition requiring immediate treatment.
2. Rectal Bleeding
3. Obstruction- Infection can cause scarring of the colon or intestine, which in the wrong place can block the flow of gas and stool.
4. Abscess- This is a pus collection in the pouch.
5. Fistula- An abnormal connection, a passageway, can form between the intestine and structures nearby, like your urinary bladder, abdominal wall, or vagina.

Is there a connection with colon cancer?
A direct connection has not been found, but diverticulosis can make cancer harder to diagnose.
After you recover from an episode of diverticulitis, it may be advised that you get a colonoscopy, and more frequent colonoscopies than the average person to screen for cancer and other abnormalities.

What is the treatment for diverticulitis?
This depends on the severity of your condition, and if it is your 1st time. Mild symptoms typically require a liquid or low-fiber diet and antibiotics. Usually the symptoms lessen in 3 days and you can start increasing your fiber intake then. Stronger pain medication may be needed but watch out, it can worsen constipation and thus the problem.
More severe symptoms and signs, or the increased risk of obstruction or peritonitis, calls for hospitalization and intravenous antibiotics.
The most severe cases, involving perforation, abscess or fistulas may need surgery to remove that part of your colon. One kind of surgery involves removing the diseased portion and sewing the 2 ends back together.
More severe and generalized inflammation requires the 2nd kind which involves the surgeon making an opening (stoma) in the abdominal wall. The healthy portion is connected to that stoma and your waste will pass from that healthy end into a bag attached to the outside of your body, called a "colostomy bag."

How can I prevent diverticulitis?
We cannot say it enough, an ounce of prevention is worth a pound of cure.
1. Eat More Fiber: The National Fiber Council recommends that a healthy adult consume 32 grams of fiber a day. The average American eats about 10-15 grams. The NFC says only about 10% of Americans eat enough fiber. Why? Many Americans are misinformed about foods containing fiber. For example, 53% of American believe steak is a good fiber source, and most meat products contain little or no dietary fiber.

2. Drink Plenty of Fluids. Water is absorbed by fiber. This increases the soft, bulky waste in your colon. If you eat fiber and drink little water, you risk constipation.

3. Respond to the Urge to Defacate (Pass Stool). Holding in bowel movements makes stool harder, which requires more force from the colon to pass it.

4. Exercise. This increases bowel function and lowers the pressure inside the colon. Thirty minutes of exercise on most days of the week is all you need.

Be safe, be successful,
Rapp, M.D.

Lil' Wayne, Me, and Gun Safety

Lil' Wayne and I have some things in common. We were both good students, smart kids, who, at the age of 13, handled the gun of an older relative. Holding the handle, I avoided the trigger, but silently, stared down the barrel until I could make out the bullet. I put the gun back in it's worn paper bag, and back into my Grandmother's nightstand.

Lil' Wayne's gun went off and the bullet went through his chest, just missing his heart. He described slipping in his own blood trying to get help.

Many people believe that having a gun in the home provides safety in the case of home invasion. In 2009 it was estimated that 1/2 of American homes have guns. Pediatrics' Gun Safety Guide states that a firearm in the home is up to 43 times more likely to kill or injure a family member or friend than an intruder.

Picture a curious child. See that spouse in a fit of rage against the other, or suicidal thoughts brought on by alcohol and drug use, poor health, poor finances. According to the 7/17/1989 Time magazine article, covering the week of 5/1/89 to 5/7/89, during which 464 U.S. gun deaths occurred, "Despite the cry over street gangs and drug dealers, the week's homicides typically involved people who loved, or hated each other....People in the grip of despondency or disease who turned their weapons on themselves accounted for 216 deaths, nearly half the total. This article, published before my senior year in high school, with its stories of suicide, unintentional gun deaths and so many faces to go with them, convinced me to pursue a career in medicine.

These figures are old I know, and fortunately, the numbers have gone down, but any gun death, with suicide and unintentional gun deaths being especially preventable, is one too many. In 2005, 68% of unintentional gun deaths and 75% of suicides using firearms occurred in the home, occurred in the home according to the CDC's Morbidity and Mortality World Report (MMWR) in April, 2008.
In May, 2010, the MMWR reported that in 2007, 57% of deaths were suicides, and 0.7% were unintentional gun deaths. How many occurred in the home? An average of seventy percent occurred in the home and 51% involved guns.
The highest number of unintentional gun deaths that year occurred in ages 15-19. Parents probably assume kids in this age group know better. Twenty-three percent of those deaths occurred while playing with the gun.

Numerous intellectual outlets, have found that the trend in the data found was that, "both firearm prevalence and questionable storage practices (i.e. storing firearms loaded and unlocked) were associated with higher rates of unintentional firearm deaths." This quote is from the Harvard Injury Control Center, which did a review of 24 articles featured in publications such as Aggression and Violent Behavior, Journal of Trauma, American Journal of Public Health, Pediatrics, and Injury Prevention. This of course also applied to completed suicide attempts and homicide. Lastly, thousands of guns are stolen every year.

What can you do?
1. Lock your handguns. Check for local gun shows for information or even a free lock.
2. Store them unloaded
3. Separate ammunition from the gun and store in a locked container.
4. Apply external safety devices to your gun. Your local police dept. might provide them.
5. Address the curiosity of children in the house, and alert them to the dangers of handling a gun, so they don't find out on their own, alone or with friends.


The Eddie Eagle Program sponsored by the National Rifle Association has advice for children when they come across a gun:
1. STOP!
2. Do not touch it!
3. Leave the area.
4. Tell an adult!



Had I not been so lucky during my few minutes of very poor judgment, I may not have been able to give you this information. I may not have been here at all. Too many loving and talented people were not so fortunate, and we'll never know what they had to offer.

For more information, see About.com's Pediatrics Gun Safety Guide and the Kids' Health's Gun Safety page.


Be safe. Be successful.
Rapp, M.D.