HIPAA Compliant Text Messaging (for Free)

Let's face it...

Physicians love to text message given it is fast, easy, and convenient. However, regular instant messaging (SMS, MMS) that comes with your smartphone is not secure, saved unencrypted on a server somewhere (forever), and most importantly not HIPAA or HITECH compliant.

Enter the encrypted and HIPAA compliant messaging services.

Though most of these services cost a nominal fee per month, there are a few and growing number of services which offer free and secure instant messaging. Even better, pretty much all these services including the free ones allow sending messages with unlimited characters, pictures, video, and audio along with text.

Regardless of the service, there are two elements that allow for encrypted SMS and MMS.

1) Userid and Password
2) All your secure contacts must also be using the same service (ie, they all have to sign up before using)

The best free HIPAA-compliant messaging services that's out there that I'm aware of are qliqConnect which is geared towards health professionals and Wickr which is geared towards anybody.

There are pros and cons to both.

qliqConnect is available for use on the desktop, iPad, iPhone, and Android. Wickr is available only on the iPhone (Android coming soon).

Wickr offers complete self-destruct of messages after a certain period of time (all metadata with pictures, video and audio files, like your device info, your location, and any personal information captured during the creation of those files). qliqConnect does not.

No email is required with Wickr. qliqConnect does.

Wickr also states that messages are secured using military grade encryption that exceeds HIPAA standards and unencrypted messages are NEVER stored on any server. It is unclear whether qliqConnect offers similar level of security.

Depending on your needs, one of these free services may be more suitable than the other.

Of course, the weakest link for full adoption is that everybody you want to securely message with also needs to sign up for the same service.

In the end, if I'm a betting man... Wickr will probably win out in the end, especially once they have software available for platforms beyond the iPhone.

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Embedded Earrings and Treatment

A few times a month, I have a patient, usually a young child, who presents with an earring that not only can not be removed, but is embedded within the earlobe (or ear) itself.

There are two common scenarios that lead to this unfortunate situation: infection and fiddling.

Infection is fairly straightforward. For whatever reason, the piercing gets infected and the earlobe skin starts to swell around and eventually even enveloping the earring itself. To prevent an embedded earring, immediately remove the earring!!! If you wait until the swelling is too severe, it may not be possible to remove the earring at all without surgical intervention. This type of infection can occur rapidly from being normal to rip-roaring infected swelling within 24 hours.

Fiddling is basically when the patient keeps tightening the earring backing snug with the skin as tightly as possible so the earring won't loosen and potentially get lost. However, such tightening can actually induce the skin to overgrow the earring with subsequent infection. To prevent this from happening, always make sure there is some “play” that allows the earring to push back and forth through the ear and turn easily.

Now, should the earring become embedded and manual removal not possible, surgical intervention is required.

The steps are as follows:

1) Sterilize the area with betadine.
2) Inject area with lidocaine.
3) After the area becomes anesthetized, a scalpel is used to create an "X" shaped incision over the embedded earring.
4) Toothed forceps and clamps are used to grab and pull the embedded earring out.

Aftercare typically involves oral antibiotics and application of antibiotic ointment several times a day. Once the infection clears, I typically recommend waiting a few months before re-piercing to allow scar activity to completely fade first.

Also, keep in mind that they DO make earrings that are physically impossible to tighten up against the skin to reduce the possibility of embedded earrings.

On that note, we do offer ear-piercing in our office.

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Actress Jennifer Aniston Underwent Septoplasty Twice

Though not entirely recent news, actress Jennifer Aniston reportedly underwent septoplasty nasal surgery not just once, but twice. The first was done in 1994 and a revision septoplasty was performed in January 2007. [link] [wiki]

This type of surgery is performed to help improve nasal breathing, an issue that Jennifer Aniston apparently had.

Septoplasty, unlike rhinoplasty or nosejob, does NOT change the outside appearance of the nose. All the work is done internally. (Watch video here).

The explanation for why the nasal appearance does not change after septoplasty is actually quite simple. The analogy would be a house where the appearance on the outside would not change even though you may knock down a wall between two rooms inside the home.

SO... Here is a side view of the septum. The blue arrow is pointing to the nostril opening and the red arrow is pointing to the lip.

In this picture below, the septum has been removed.

As you can see, the outside appearance of the nose remains unchanged as the rim of the nose is kept intact as shown by the red arrows here:

So that in a nutshell is the explanation for why deviated septum surgery does not change the outside nasal appearance.

The way the deviated septum itself is removed can be more simply understood looking at the nose from a different vantage point.

Step 1: A small incision is made inside the nose and the mucosal lining carefully lifted away from the septum on one side. It is during this stage of the procedure that one of the complications of the procedure, septal perforation, may occur. This complication occurs when the lining gets torn resulting in a hole as the mucosa is lifted away from the septum.
Step 2: The septum is incised immediately in front of the deviation and the nasal mucosal lining is lifted away from the septum on the opposite side.
Step 3: The deviated septum is now physically removed. One removes the deviated septum completely instead of forcing it into a midline position. Why? Because just like a young tree sapling, the nasal septum has "memory" and bending or forcing it into a certain position will last only temporarily before it springs back into its original position.
Step 4: The nasal mucosal lining is reapproximated in the midline. There are several methods how this last step is performed. One method is to suture the lining back together like a quilt (NO nasal packing or septal splints are used). Occasionally, the nose is packed with septal splints or nasal packing material. Both methods are used in our practice depending on the physician and the condition of the septum itself.

Read more about the septoplasty surgery here or watch a video!

Source:
The one where Jennifer Aniston Fixes Botched Surgery. PopSugar 6/7/10

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Celebrity Actors Who Have Received a Trach (Catherine Zeta Jones Included)

Image Taken From www.TopScarCream.com

Tracheostomy (also known as trach) is when a hole is made in the midline neck directly into a person's windpipe (watch video). Although many people may shy away from this deforming procedure, it can be life-saving.

On that note, here is a short list of famous celebrity actors who have undergone an emergency trach for one reason or another:

Catherine Zeta-Jones
Apparently, when she was a child, she had an emergency trach done. She still has a 1.5 inch scar from this procedure which she elected to not have removed [link].

Gary Coleman
He was hospitalized for 3 months due to complications from thyroid surgery for which he underwent an emergency trach [link].

Watch video of thyroid surgery.

Elizabeth Taylor
In spring of 1961, she developed a case of pneumonia which led to an emergency trach [link].

Christopher Reeve
Of the original Superman fame, he became paralyzed from the neck down after a horse-riding accident. A tracheostomy was required for him to breath due to ventilator dependence. [link]

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Brain Fluid Leakage Out the Nose (CSF Leak)

Image by Patrick Lynch from Wikipedia

Fox News published a story today (12/3/12), describing one patient's runny nose that was not due to allergies, but in fact due to brain fluid leaking through a crack in the roof of her nose. Also known as CSF leak (cerebrospinal fluid leakage), correction of this problem can be performed endoscopically through the nose without any incisions on the face.

An interesting trivia related to CSF leaks is that actor George Clooney suffered one after a blow to the head while filming a torture scene in the 2005 movie "Syriana".

Diagnosis can be obtained simply by taking some of this nasal drainage into a red-top tube and getting it tested for beta2-transferrin which is a protein found in brain fluid, but not in normal nasal secretions.

The take-home message is that not all runny noses are due to allergies, especially if it is continuous and only occurs on one side.

Of note, the Washington Post also published a similar story of a different patient with the same problem in 2010.

Source:
Woman's running nose revealed to be leaking brain fluid. Fox News 12/3/12.

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57 Maggots Removed from Woman's Ear

92 years old woman with Alzheimer's was found to have 57 maggots in her ear sparking a lawsuit. Read more from media reports.

Beyond the gross factor and questions regarding how this was allowed to happen, this story does bring up some interesting teaching points and the medicinal properties of "maggot therapy".

Media reported the patient suffered from earwax build-up and had "an enlarged ear canal from surgery performed decades earlier."

This  surgery was most likely a canal-wall-down tympanomastoidectomy often performed for a benign ear tumor called cholesteatoma or a severe chronic draining ear. This surgery essentially removes all the bone from behind the ear (mastoid) and ear canal back wall. Depending on how aggressive the surgery, the eardrum and middle ear bones (malleus, stapes, and incus) may also be removed.

With such surgery, the ear canal now 2-3 times larger than before, is prone to developing earwax impaction and requires surgical debridement or removal every 4-6 months for the rest of the patient's life.

If surgical debridement is not performed regularly in such patients, infection may set in.

With such infection, ear drops can be used as described in the story, but such treatment is bound to fail until ear canal debridement of all earwax is first performed.

What I suspect is that this poor patient did not get her ear cleaned out regularly resulting in infected earwax. A fly noting the foul cesspool located in a dark, humid environment of this enlarged ear canal probably thought this the perfect place to lay eggs and allow a maggot infestation to occur.

Gross, horrid, and astounding I know...

However, medicinal maggot therapy is actually used in hospitals... Why?

Because maggots are apparently WAY better than a surgeon in certain situations at removing dead infected tissue with or without antibiotics.

It is entirely possible that given time, the maggots might have cleaned and removed the infection that was probably present in this patient's ear. However, unlike medical-grade maggots which are "sterilized" prior to use, "natural"maggots probably harbor other microbes that could cause a secondary infection.

Such medicinal maggots can be purchased for wound control with a prescription. Monarch Labs is the exclusive USA supplier of medicinal maggots which the FDA considers a "medical device."

Here is a video produced by National Geographic on maggot therapy.

Source:
92-year-old has 57 maggots removed from ear, family sues nursing home. CBS News 11/30/12

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Egg Free Flu Vaccine Approved by FDA

Why the concern of egg-allergic patients with the flu vaccine used to defend against both seasonal and pandemic flu virus?

Traditionally, the flu shot vaccine (both H1N1 and seasonal) are grown inside eggs which is where this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, during vaccine production the egg protein is filtered out such that there should be no egg contaminants in the final vaccine. However, it is theoretically possible that some egg may still be present in the vaccine.

Although there is an infinitesimal possibility of egg contaminants, studies have shown that even patients with life-threatening egg allergy can still safely have the flu vaccine.

In spite of these reassurances, there are still concerns from patients and healthcare professionals.

As such, there is now a new FDA-approved flu vaccine called Flucelvax which is guaranteed to be egg-free. Rather than being cultured in eggs, this vaccine is cultured in mammalian cells.

Downside is that latex-allergic patients are unable to safely receive this vaccine.

Made by Novartis, this vaccine is approved for use in people 18 years and older.

For more info.

Source:
FDA approves first seasonal influenza vaccine manufactured using cell culture technology. FDA 11/20/12

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