This page last updated 03/18/2017

SGYC Marine Medical Information

Dr. Mark Monroe has been appointed the SGYC Fleet Surgeon. In that capacity, he will present medical information germane to yachting and SGYC issues. This information will be presented in brief articles with an index at the top of the page. It would be prudent for all members to review these articles to assure they are aware of medical issues related to all boaters.

 

Index of Marine Medical Information

SGYC Magnetic Name Badge Medical Alert

by Mark N. Monroe, M.D.

Be advised that our new “Magnetic Name Tags” should not be worn by any person with a pacemaker. If you have had a pacemaker inserted and also have a SeaGate Yacht Club name badge with a magnet, please discontinue its use immediately! Please contact our Membership Chair, Aurelia Okino, E-mail: okinos@att.net or (714) 625-2512 in order to obtain a replacement badge with a pin closure.


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2017 Motion Sickness Update

by Mark N. Monroe, M.D.

Shannon asked me if there is anything new, improved, and preventative for motion sickness that is non-drowsy. This is an update of my 2004 article.

As Ian Cameron Smith stated in his book MOONRISE: “There are two types of people in this world: those who are terrified of going out in the ocean in case they spend the entire time barfing, and those who think they have guts of steel until they get out in the ocean and spend the entire time barfing.”

Many people believe that there is the third type of people who seem to be able to cruise around the world in small boats without ever feeling seasick. Sensible sailors know that seasickness is just part of the game and needs to be handled properly. To properly handle it, one should understand the anatomy and psychology of seasickness and the steps to prevent and treat it once one gets it.

Many people think that seasickness occurs in the stomach, but actually, it is due to over stimulation of the sensory hair cells in the semi-circulatory canals in the inner ear by excessive motion of the endolymph fluid. This is where the person’s balance mechanism is. You can get dizzy (vertigo), nauseous, and loss of equilibrium. It takes on the average about 3 days to get your “sea legs” once you get on the boat and about the same time to get your “land legs” once back on land. Roll in rhythm with the boat’s motion as fighting it can cause fatigue and seasickness.

The psychology of seasickness can be the power of suggestion, i.e. certain smells, someone talking about it/getting seasick, or going down below inside the cabin thus losing sight of the horizon. Stay facing forward in a well ventilate place outside near the center of the boat or front seat of a car. Keep your eyes on the horizon, stay on deck steering the boat or on the look out, and keep yourself well hydrated with non-alcoholic and decaffeinated beverages. Avoid bad smells or even strong perfumes can bring on nausea.

Nutrition is extremely important in prevention of seasickness and should be started the day before sailing. Avoid alcohol, rich, spicy foods, i.e. pizza, as they will stimulate more acid production in your stomach. The day of the sailing try to eat oatmeal, bread products, crackers, and foods that will help absorb the acids. If you start feeling queasy, take 2 TUMS right away and more, as needed. Ginger, either in ginger ale, candy, gum, or powder form (it can be found in a Japanese market), can be very effective once the seasickness starts or as a preventive measure. Take 1 gram per teaspoon of ginger powder with 8oz of water. Ginger candies or gums are quite effective also, although some swear that the taste of the candy is worse than the sickness. Non-pharmaceutical remedies such as manual or electronic wrist bracelets stimulate wrist pressure points to prevent motion sickness as long as you keep moving your wrists or until the batteries run down.

Pharmaceutical alternatives include: TRANSDERMSCOP 1.5gm patch, SCOPOLOMINE tablets, antihistamines, such as dimenhydrinate (Dramamine), diphenhydramine (Benadryl), cinnarizine (Stugeron), meclizine (Bonine), promethazine (Phenergan), anti-seizure (phenytoin) medication, and combination of antihistamines with stimulants. The cruise ships use meclizine (Bonine) a lot. The antihistamines can produce drowsiness; therefore they were combined with stimulants, such as dextroamphetamine, ephedrine, and pseudoephedrine (Sudafed). Only Sudafed is available over the counter since stimulants can lead to drug abuse. It is contraindicated for people with hypertension or arrhythmia. Phenergan is the only one available in oral or rectal suppository form (if you are already vomiting). Stronger Zofran (ondansetron) which is prescribed for nausea/vomiting prevention or treatment for chemotherapy or post-op is the latest but contraindicated in liver disease. It comes in 4 & 8 mg swallow tablets, Oral Disintegrating Tablets on the tongue, and injectable forms. Some medications require prescriptions (Rx), and some are over the counter (OTC). Prevention by starting the medications the night before travel is the most successful. Your doctor would be the best one to advise you and should explain to you all possible side effects and drug-drug interactions of prescribed medications.


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Shallow Water Blackout

by Mark N. Monroe, M.D.

Q: What is shallow water blackout and what can I do to prevent it?

A: Shallow water blackout is loss of consciousness due to cerebral hypoxia while a swimmer holds his breath freediving up to 30 foot depth. It can be provoked by hyperventilating (breathing rapidly) before submerging. Unlike scuba diving where pressure is a factor, free diving blackout is the result of lack of oxygen going to the brain. Just like in scuba diving, you need to have a diving buddy to rescue you from drowning immediately and start CPR. Free diving blackout can occur at any depth: constant, ascending, or descending depth. Hyperventilation blows off your carbon dioxide drive that is needed by the brain to monitor the oxygen level.

If excited or anxious about the dive, the diver should take extra care to remain calm and breathe naturally as adrenaline can cause hyperventilation without the diver noticing it. When the urge to breathe comes on at the end of the dive, the diver should slowly exhale, surface immediately, and then breathe. A diver should never free dive alone. Diving in buddy pairs, one on the surface to observe and one to dive, allows the observer to attempt to rescue in the event of blackout. Buddy pairs should both know how to recognize and manage the blackout. After surfacing, the divers should observe each other for at least 30 seconds. Dives should be kept within the rescue capabilities of both divers. Contact your family doctor as he will be most familiar with your physiological needs. Stay safe and have fun!


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Restless Legs Syndrome

by Mark N. Monroe, M.D.


Q: My bunk mate complains that I kick my legs while asleep. I saw my Family doctor about it. He thinks that it might be Restless Legs Syndrome. What is it and what can be done about it?

A: The clinical diagnosis of Restless Legs Syndrome (RLS) requires 4 ingredients:

1. A strong urge to move the legs usually accompanied by an uncomfortable sensation like pins and needles or muscle cramp
2. It occurs during periods of inactivity like sitting or lying
3. It is relieved immediately by leg movement like walking or stretching
4. It is worse at nighttime than daytime

RLS occurs in about 10% of the U.S. population and 3% of the Asian population. Males=Females. Primary RLS is genetic ( dominant inheritance chromosome 12q) , incurable, but treatable whereas Secondary RLS is due to other medical conditions like Iron Deficient Anemia, Electrolyte Imbalance (i.e., Magnesium, Calcium, Sodium, Potassium), Sleep Disorders (i.e., Obstructive Sleep Apnea, Insomnia), Age, Parkinson’s Disease, Varicose Leg Veins, Diabetic Peripheral Neuropathy, Kidney Disease, Pregnancy, and Depression. These must be diagnosed and treated first, if possible.

Laboratory blood tests including anemia panel, complete metabolic panel, dopamine level as well as an overnight sleep study with a Suggested Immobilization Test (SIT) before a Nocturnal PolySomnoGraphy (NPSG) and a thorough history and physical exam by your family physician can help make the diagnosis.

Treatment includes avoiding caffeine, alcohol, and tobacco. Dietary supplements that may be helpful include iron, folate, calcium, vitamins B12, C&D, and magnesium. The quinine in Tonic Water has anecdotal evidence but prescription quinine is no longer approved for anything but malaria by the FDA due to the risk of Prolonged QT arrhythmias. FDA approved prescription medicines include dopamine, Requip, Mirapex, Sinemet, Neurontin, Tegretol, and tranquilizers/sleep aids. It would be best to discuss this with your family physician.

For further information, you can contact the Restless Legs Foundation @ www.rls.org or tel. 1-507-287-6465


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DUCT tape for Blisters

by Mark N. Monroe, M.D.

Lloyd asks: My wife wore new shoes on our vacation and got painful blisters on her feet. What could we do to prevent ruining our vacation?

Blisters are very common ailment especially with new shoes and/or a wet environment. They are caused by chafe which causes friction and heat build-up. Moisture softens the skin thus making it more likely to develop the blisters. Wearing thick socks will help prevent the chafing. Nylon stockings do not protect your feet from chafe. As soon as the red tender hot spot is detected, try to cool your feet in cold water and then dry them very well. Stop the friction by using moleskin tape which is available in large drug stores, or using duct tape which is available pretty much everywhere. Tincture of Benzoin topical solution can be applied to skin to prevent adhesive tape irritation. It is available in most drug stores and should be in your first aid kit anyway. Never use Gorilla tape as that will pull your skin off when it’s time to remove it.

Once the blister has formed, do not try to pop it on your own as your intact skin is the best barrier against infection. Use silver sulfadiazine 1% cream (if not allergic to sulfur) on a Band-Aid to cover the blister. Then use a large piece of duct tape (twice as big) on top of the Band-Aid to further protect the injured skin. You should do it twice a day until the wound has healed. The duct tape has no elasticity and should not stretch out of shape. Do not wrap the duct tape all the way around your foot as it may act as a tourniquet and cause a painful and dangerous compartment syndrome.

Contact your family doctor as he/she will be the best person to advise you.


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Fish Hook Removal

by Mark N. Monroe, M.D.

Lloyd asks: On a past cruise to Mexico, we were trolling for fish behind the boat and accidentally got a large fish hook caught in one of the crewman’s leg. We did not know how to remove it and had to send him by air ambulance to San Diego to have it removed. Is there an easy painless way to remove a fish hook without causing complications?

First one needs to know the anatomy of the hook. There is the eye for tying the fishing line, the shaft which may have barbs on it, the bend, and the final barb or harpoon end. There are number of methods to remove the fish hook such as Pass Through, Cut Down, and the Snatch methods. The best method is the Snatch method. First, detach the fishing line from the fishing pole. Take a 6 inch loop of 10lb test monofilament fishing line and loop it around the bend of the hook. While gently pressing on the eye of the hook to dislodge the barb, pull on the 6 inch loop to pull the barb out of the skin. It is quick, simple, and relatively less painful as long as you get it right and quickly on the first try. Patients usually won’t let you try again without local anesthetic. If possible, try to clean the area with Betadine solution or soap and water if the patient is allergic to iodine. This technique changes the angle of the attachment of the harpoon end of the hook away from the underside of the skin. I use 10lb test because it is more likely to break before tearing any nerves or blood vessels on the way out. If there is bleeding, put compression on it for 10-20 minutes with a sterile gauze or clean towel.

After cleaning the wound with Betadine and hydrogen peroxide, apply antibiotic ointment that the victim is not allergic to and bandage the wound. Tetanus (i.e. lockjaw) vaccinations should be routinely done every 10 years. They should be given every 5 years if you get cut. Always contact your family physician for further evaluation and treatment. So be careful out there and catch lots of fish, not humans.


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Weekend First Aid Kit

by Mark N. Monroe, M.D.

I have been recently asked again: "What should be in a good first aid kit for the weekend trip to Catalina?".

Here it is!

First aid kits should be classified four ways:

I. A readily available first aid kit for handling minor cuts, scrapes, sunburns and seasickness.
II. A bigger first aid kit that can help with second degree burns, fractures, sprains, etc. until outside medical assistance is available.
III. First aid kit with medications.
IV. Customized first aid kit.

All First Aid kits should be stored in the waterproof plastic container to keep the moisture out. The alternative is a canvas bag with contents in ziplock bags deflated of air.

I. A readily available kit should contain Betadine (Hibiclens if allergic to iodine) antiseptic solution and soap with a scrub brush. Individual packets are preferable and available from pharmacies and medical supply companies. Sterile gauze dressing pads, Kling roll bandages, Telfa ouchless bandages and waterproof adhesive tape as well as band-aids, steristrips, Tegaderm waterproof plastic dressings, Dermabond (super glue) and Spenco second skin glues are all good first aid kit stuffers. You should also include Bacitracin antibiotic ointment, Silvadine burn cream, Caladryl rash lotion, Lotrimin anti-fungal cream, Hydrocortisone 0.5% itch cream, Solarcaine (pain relief) analgesic spray, tweezers, scissors, small flash light, q-tips, sterile gloves, eye patches with a bottle of buffered eye irrigation solution, an extra pair of sunglasses and #18 SPF sunscreen.

II. This first aid kit is much more extensive in its contents. It should include: instant cold packs, dental glue for emergency broken tooth repair, splints, sling, safety pins and elastic 2/4/6" ace bandages. Digital blood pressure/pulse meter and stethoscope are good to include also.

III. The medications that are included in this first aid kit should be updated every six months. It's best to store them in the waterproof ziploc bags. The following medications included but not limited to:
a) Dramamine, Bonine, Phenergan(liquid, tablets and suppositories), Transderm-scop patches, accupressure wrist straps and Japanese ginger candy (in a very minute quantities as they are very strong);
b) Benadryl (for allergies or seasickness or insomnia);
c) Analgesics such as Tylenol, Motrin, Aspirin;
d) Immodium or Pepto Bismol for diarrhea;
e) Zantac or antacids for indigestion;
f) Ana-Kit for severe allergic reactions such as bee stings;
g) Ipecac for inducing vomiting in case of accidental poisoning;
h) Floxin antibiotic eye and ear drops.

IV. Customized kit should include an extra set of the medications that you regularly use and you might forget at home such as an inhaler for your asthma, heart and blood pressure medicines, etc.

REMEMBER TO KEEP ALL MEDICATIONS AWAY FROM CHILDREN! Make sure all your guests bring their own medications.


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The Facts About Zika Virus World Epidemic

by Mark N. Monroe, M.D.

Q: My niece, her husband, and a 2-year-old son went to Rio de Janeiro for Carnival. The World Health Organization has come out with the travel warning for travel to Brazil. Should I be worried?

A: The short answer is NO. The long answer is that Zika virus can give flu-like symptoms for about 2 weeks including muscle aches, body aches, fever… However, if your niece gets pregnant and gets infected with Zika virus, the virus can produce microencephaly in the baby which can cause learning deficits. The virus can be spread by the transmission of body fluids (such as sex) or through a vector (such as Aedes aegypti or Aedes albopictus mosquitos). These mosquitos can also carry Dengue Fever or Chikungunyan Fever. The Anophales mosquito can carry malaria. The Culex mosquito can carry the West Nile virus which causes deadly encephalitis. Zika virus originally started in Western Africa and has spread to Southeast Asia, South America, and North America. 12 out of 58 California counties have Aedes mosquitos. Nationwide, Aedes mosquitos are found in Eastern and Southern states, including California. Interesting facto to know is that Aedes mosquitos are not born with the virus. They bite someone already infected with it and then spread it to someone else. Mosquito larvae eggs need standing water to hatch. Inspect your home to make sure that there is no standing water.

The best way to prevent these mosquito bites is to use 2 FDA approved mosquito repellents: either 30% DEET such as in Johnson Off or Lemon Eucalyptus Tree Bark Oil such as in Repel. Read the fine print on the label to make sure it contains one of these two ingredients or contact your family doctor for advice.


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Jet Lag

by Mark N. Monroe, M.D.

Q: Roy asks, I just back from one week in Paris, France. I still sleep on their time and can’t sleep on our time here. I tried over the counter sleep remedies without help. What can I do?

A: Jet Lag is the desynchronization of an individual’s internal clock called Circadian Rhythm. This clock determines when adrenaline shuts down in order to sleep and starts up when it is time to wake up. Without sleep medications to induce and maintain sleep, the guideline was one day recovery per time zone crossed. Jet lag is more so in professions such as pilots, crew, and frequent travelers that do not have the luxury of a prolonged recovery. The FAA has strict regulations at combating pilot and crew fatigue caused by jet lag and what medications can and can not be used. Second shift workers also suffer from it when they work nights weekdays but want to be with their families during the daytime weekends.

Symptoms can include difficulty in falling asleep and staying asleep, daytime fatigue, poor memory and concentration, headaches and irritability, and constipation.

Light is the strongest stimulus for maintaining a person’s sleep-wake schedule as discovered by the US Navy’s Submarine Service. The best way to avoid jet lag is to keep the same schedule all the time every day without any changes. However, if this is not possible, then a four hour sleep inducer like Diphenhydramine (i.e.., Tylenol PM,Benadryl) 50mg or triazolam (i.e..,Halcion) 0.5 mg nightly for 3 nights in a row at the new schedule should do the trick. Avoiding any caffeine products during this 3 day period is required as the caffeine counteracts the sleep inducer.

Your family physician would be the best person to advise you on this issue.


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Ring Rope Trick

by Mark N. Monroe, M.D.

Q. My wedding ring is stuck as my finger got swollen and I don’t want to cut it. I already tried elevating my hand, lotions and soap, and even putting it in ice water without help.

A. We use a ring cutter in the emergency room. The removed ring will then have to be taken to the jeweler for repairs which could get pretty expensive. I have found a better way to remove the ring. I use a cotton or silk ribbon (like for gift wrapping) that is ¼” wide and 24” long. I pass about 6” of the ribbon underneath the ring by lifting the ring gently on the palm side towards the palm. I wrap tightly the long end of the ribbon from the ring to the tip of the finger thus reducing the swelling of the finger. Tie or tape the end of the ribbon to the tip of the finger so that it doesn’t unravel. Then I rub a little bit of dishwater soap underneath the ring while rotating the ring. Next, I pull the short end of the ribbon that is underneath the ring allowing the ring to progress down the wrapped finger. Remove the ribbon once the ring is off and take the ring to the jeweler to have it re-sized. Do not use very thin ribbon (such as dental floss) as it may cut your finger and cause infection.

Please contact your family doctor if you have any problems.


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Flu

by Mark N. Monroe, M.D.

Q: I have fever, chills, stomach cramps, diarrhea, cough with yellow phlegm, burning mid chest pain, head and chest congestion, wheezing, muscle aches and weakness. What should I do?

A: The flu season is upon us. Every year the Federal Center for Disease Control in Atlanta, Georgia tries to predict the flu strains for the up-coming flu season. The 2015-2016 flu vaccine contains 3 strains: type A (H1N1 and H3N2) and type B. If you already have the flu symptoms, then you should get treated first before getting vaccinated. EVERYONE should have gotten vaccinated by now! Please remember that if you are allergic to eggs or any ingredients in the vaccine or if you have a history of Guillian Barre syndrome, you should not get vaccinated. There are some simple steps to lessen the chance of contracting the flu. Wash your hands frequently. Use the hand sanitizers as often as you can. Get plenty of rest and follow health diet for strong immune system. If all fails and you do get the flu symptoms, go see your family doctor right away. Starting the treatment within 24-48 hours from onset of the symptoms will make the recovery so much easier and faster. Stay well!


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UPDATE ON SUNBLOCK

by Mark N. Monroe, M.D.

Josef asked if there was any update on sunblock as their doctors keep on finding sun-caused pre-malignant skin grows even though they are using over-the-counter sunblock.

There is recent research at the University of California, Riverside, that was published in 2013 that updated original FDA’s recommendations of 2009. SPF, or Skin Protection Factor, is a measurement of how effective the sunscreen is in preventing sunburn. For example, if you normally burn in 10 minutes, SPF of 15 will multiply this time by 15 i.e. 150 minutes before burning. It is best to re-apply the sunscreen after 2 hours. No sunscreen is waterproof and can be diminished with swimming, rubbing, or wiping off. The ultraviolet rays can be in either UVA or UVB frequency range. Many former over-the-counter sunscreens did not block UVA radiation which does not primarily cause sunburn, but can increase the rate of aging, photo dermatitis (brown sun spots), pre-malignant and malignant skin lesions, such us basal cell cancer, squamous cell cancer, or malignant melanoma. Broad spectrum sunscreen covers both UVA and UVB frequencies. The FDA set out the comprehensive set of rules in 2011 to take effect in 2013 designed consumers identify and select suitable sunscreen protection products.

The two ingredients that have been approved by the FDA are Zinc Oxide and Titanium Dioxide. In the past, it was 3-4% of active ingredient but now it is recommended 9-10%. The best sunscreen is still broad brimmed hat, polarized UVA/UVB wrap-around sunglasses, and long sleeve shirts and pants. Light colored cotton fabrics are the best alternative to sunscreens. When selecting the sunscreen, pay close attention to active ingredients on the label. If you cannot find the right sunscreen locally, check the internet for alternatives.


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Measles Epidemic of 2014-2015

by Mark N. Monroe, M.D.

By 2/1/2015, there have been close to 100 cases of Measles reported since 12/15-20/2014 initial exposure at Disneyland. The majority of these cases have been unvaccinated children as the MMR vaccine (Measles (Rubeola), Mumps, and Rubella(German Measles)) has a 93 percent protection rate after the first dose and 97 percent protection rate after the second dose. The first dose should be administered between 12 – 18 months of age and the second one at the age of 4 – 6 years old. There had not been a previous case of measles in the United States since 2000. The myth that MMR vaccine causes autism was the result of the erroneous report in British magazine Lancet by Dr. Andrew Wakefield in 1998. The Lancet retracted the report in 2010 and British officials revoked his license to practice medicine. In the report, Dr. Wakefield had manipulated the data in order to show that the vaccine was associated with autism. This has since been proven a deliberate fraud. Similar myth occurred in 1982 documentary on the NBC affiliate titled DPT: Vaccine Roulette which claimed there were serious questions of DPT vaccine safety. Dr. James Cherry, UCLA research professor, and primary editor of the Textbook of Pediatric Infectious Diseases, showed there was no relationship to any “severe neurological illness”. The mercury preservative used in routine childhood vaccines – ethyl mercury- is nontoxic. It is eliminated from the body quickly and doesn’t accumulate unlike methyl mercury, such as in tuna fish. It’s like comparing ethanol in wine versus methanol in moon shine that can cause blindness. All 50 states require vaccinations for students. Huntington Beach High School required the vaccinations and banned non-vaccinated students from classes for a month hopefully until this epidemic resolves. The initial symptoms are coughing, runny nose, red watery eyes, and high fever are common to many illnesses. The red rash begins 3-5 days after initial symptoms and quickly spreads all over the body. The initials symptoms appear 10-14 days after exposure. The rash is made up of flat red patches that often flow one into another starting at the face and spreading outwards. The communicable period starts 4 days before the rash for 8 days total. The telltale is the appearance of Koplik’s spots, tiny white spots with bluish white centers on the red background. They are found inside the mouth. Complications can include ear infections, encephalitis, pneumonia, dehydration, shock, and even death. If you are pregnant, you can even miscarry. Treatment includes hydration, orally or IV, fever control, and isolation as this is an air born virus. It’s much better to have the vaccine than to have the disease. Please call your doctor and don’t go to his/her office if you think you have been exposed. If you must know more about the measles, you can have a PCR swab test to detect it, IgM test to know if you were exposed in the last 30 days, and IgG test to find out about your lifelong immunity to measles.


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Ankle Sprain

by Mark N. Monroe, M.D.

Q: I twisted my right ankle going down the ladder on my boat. Despite elevation and ice, it swelled and turned black and blue. It was very painful and worse with walking or trying to put weight on it. What should I do?

A: A sprain is an overstretching or tearing of a ligament. A strain is an overstretching or partial tearing of a muscle. A fracture is a broken bone. A rolled or twisted ankle can cause any of these. Symptoms include inflammation, swelling, bruising, and pain worse with weight bearing or movement. Predisposing risk factors include weak muscles, tendons, or ligaments due to previous injuries, hereditary, inadequate running shoes, high heels, or elevated shoes. There are 3 grades of ankle sprains. Grade 1 is mild ligament damage without joint instability. Grade 2 is partial ligament tear resulting in a loose ligament. Grade 3 is complete ligament tear. In 1992, the E.R. physicians at Ottawa, Canada Civic Hospital published the "Ottawa Ankle Rules" with a 100% sensitivity for adults and 98.5% for children greater than 6 years old, specificity, and very low rate of false negatives for excluding fractures and the necessity of Xrays. Xrays are required if there is ankle/foot pain and tenderness within 3 inches of the edges of the ankle/foot bones and inability to bear weight for 4 steps. Exclusions include pregnancy, head/spine injury, intoxication, or children less than 6 years old. Treatment includes nonsteroidal anti-inflammatories (ie., ibuprofen, naprosyn), R.I.C.E. (Rest, Ice, Compression, Elevation), Crutches, and even immobilization in a compression Walker Boot for 2 weeks. Isometric and range of motion exercises help quicken recuperation. Isometric exercises include using opposing flexor and extensor muscles at the same time to prevent muscle atrophy. Range of Motion exercises include clockwise and counter clockwise rotation of the ankle as well as rolled up towel stretching of the foot. Your family physician would be the best one to advise you.


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Finger Amputation

by Mark N. Monroe, M.D.

On June 26th, 2015, The Tonight Show’s host Jimmy Fallon nearly amputated his left 4th ring finger when his wedding ring got caught on a table as he tripped and fell at home. He was able to save the finger and have it re-attached at the hospital. We had a similar episode at the Huntington Harbour Yacht Club when a member tripped and fell on his boat catching his wedding ring on the head of a screw amputating his finger. What should be done to prevent and treat this kind of injury? Don’t wear rings when boating. Even watches can get caught and can cause amputations of the hand and/or wrist. If an amputation does occur, put hard compression on the stump to stop the bleeding. Wrap the severed part in a paper towel and place it in a Ziploc bag. Place that bag inside another Ziploc bag with ice in it. The patient needs immediate evacuation to the nearest emergency room where the severed part can be re-attached surgically. Time is of the essence. The best outcome occurs if the re-attachment is performed within the first 2 hours of injury. Functionality can be restored with rehabilitation, but sensation may not fully return. Your family doctor can call in an orthopedic hand specialist to help you.


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Tuna Fish Poisoning

by Mark N. Monroe, M.D.

Q: On Saturday I went to a sushi restaurant and had a seared ahi salad. Within two hours I was nausea and vomiting with diarrhea, sweating, abdominal cramps, chills, and low fever 99°F. What was wrong?

A: Scombroid food poisoning is a food borne illness from eating spoiled fish such as tuna, mackerel, bluefish, bonito, mahi-mahi, sardines, and anchovies that were not stored properly. Tuna and bonito are especially prone to it since they have a long dark maroon stripe along the sides that are used by the fish for temperature regulation. However, it can carry bacteria that can produce toxic histidine which is a histamine. Therefore, patients with asthma are more prone to respiratory problems such as wheezing and bronchospasms. Symptoms can occur anywhere from 10 minutes to 2 hours after consumption of undercooked fish. These symptoms include nausea, vomiting and diarrhea to evacuate the poison from the body, rapid heartbeat, dizziness, chills, sweating, abdominal cramps, and flulike symptoms. Severe symptoms can include rash, blurred vision, respiratory distress, and swelling of the tongue. Death is rare, but has been reported. There is no laboratory test for it so it is based on clinical diagnosis. Treatment includes rehydration with at least 64 ounces of Gatorade daily, antihistamines such as Benadryl plus Zantac together, and antibiotics such as Levaquin, if not allergic. If problems breathing or anaphylaxis (swollen tongue or lips), use the Epipen (adrenalin), go to the nearest emergency room or contact your family doctor immediately.


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Total Knee Replacement

by Mark N. Monroe, M.D.

Since I am one of several members of SGYC to receive a total knee replacement, I thought it would be appropriate to discuss indications, benefits, alternatives and possible risks and benefits of this procedure. When the knee is so severely damaged by injury or arthritis to the point that the pain can no longer be managed by medications, exercises, braces, or physical therapy, then it is time to evaluate for more invasive procedures such as arthroscopy or total knee replacement.

The evaluation starts with a thorough history and physical examination. Symptoms may include pain on simple activities such as walking or climbing stairs and in severe cases even at rest. Examination can include range of motion test, loose ligaments, tears such as Lachman sign, Drawer sign, McMurray sign, or crepitations underneath the knee cap. Upright weight-bearing x-rays are a good way to see how much cartilage is left. In the case of joint space narrowing to the point that it is bone on bone that is considered severe osteoarthritis and is an indication for Total Knee Replacement (TKR). If there is torn meniscus, arthroscopic surgery may be all that is required. An MRI of the knee will confirm the diagnosis.

Although Total Knee Replacements have been performed in the United States since 1968, the technology for these procedures has improved exponentially with the use of fibro optics, titanium, and matrix polyethylene plastic joint bearings instead of Teflon thus extending the life of the joint from 10 to up to 20 years. The new surgical techniques are much improved also. Cutting from the side and underneath vastus medialis muscle vs cutting in the front, reduces the recovery time from 8-12 weeks to just 3-4 weeks. The usage of new intra-operative and post-operative pain management techniques such as epidural anesthesia, general and long-acting local anesthesia, and IV patient controlled analgesia (PCA), help the patient recover faster by controlling the pain level. Icing the new knee, pain meds and anti-inflammatories are crucial in controlling pain and swelling. CPM (Continuous Passive Motion) machine is extremely important in recovery process as it promotes faster healing and prevents the scarring of the knee.

Your family doctor would be the person to advise you in your particular situation.


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Preparation in the Event of a Helicopter Rescue

by Mark N. Monroe, M.D.

In the event that you or a crew member must be evacuated by helicopter, the U.S. Coast Guard will provide a specific list of instructions by radio. But if you know the procedure beforehand, you will be able to evacuate the injured person more quickly and efficiently.

Minutes can mean the difference between life and death, injury and health. A detailed log or record with an exact time must be kept and given to the authorities (i.e., sheriff, physician, paramedics) when requested. If you are not directly involved in the rescue, keep clear and don't get in the way.

Next, lower all antennae, bimini covers, outriggers, masts, booms, etc. Clear the deck of all loose gear and unnecessary personnel. If you have to move the victim, minimize jostling by log-rolling him/her. PUT A LIFE JACKET ON THE VICTIM with a note attached stating his condition and life signs (i.e., blood pressure, pulse, respirations, temperature (if available as in cases of hypothermia), and mental alertness (i.e., who he is, where he is, what happened, date and time) along with the recorded log as above in case the victim becomes unconscious or brain damaged from trauma or hypoxia (lack of oxygen) or air embolism (i.e., the bends from scuba diving).

When the helicopter arrives, the boat has to change course to put the wind 30 degrees off the port (left) bow as most helicopter hoists are located on their starboard (right) sides. Make contact with helicopter by VHF radiotelephone for further instructions. The rotors’ downdraft may make it difficult to control your vessel unless you maintain enough speed and steerage. The rotors are also loud, so have a designated person standing by in the cabin with a hand held VHF to relay messages or use an earphone jack.

A tether line will be lowered first into the water to dissipate any static electricity from the rotors which might shock the rescuer. Then a rescue device (i.e., a sling, litter, or basket) will be lowered on a steel cable. Have a crew member guide the rescue device into contact with your vessel. DISCONNECT THE CABLE AND LET THE HOOK END OF THE LINE GO FREE in order to put the victim in the rescue device.

DO NOT ATTACHE THE CABLE TO THE BOAT as each helicopter comes equipped with only one cable and has an automatic guillotine type cable cutter built into the winch in case of excessive load (i.e., your boat). That helicopter would have to fly back empty and a new helicopter would have to be sent out delaying the rescue.

Once the victim is in the rescue device, connect the cable only after the static electricity has been dissipated a second time. Then, signal the helicopter to hoist away with a "THUMBS UP" sign.


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Hypothermia

by Mark N. Monroe, M.D.

Hypothermia, as defined by decreased body temperature, develops faster in water than air. Water conducts heat better than air. Any movement in the water accelerates heat loss reducing survival time to minutes depending on the temperature of the water.

Cold shock is defined as the sudden exposure to cold. The cold constricts blood vessels in the arms and legs causing low perfusion of muscles and tissues. Hands, arms and legs become numb and useless. Without thermal protection, swimming is difficult if not impossible.

The victim, though conscious, is soon helpless. Without a life jacket, drowning is unavoidable. As soon as the victim falls in the cold water, he experiences an involuntary gasp reflex. Just as his head goes under water, he inhales. Once the victim is in the water, he should try to get back in or on the boat immediately if it is still floating. If you cannot get out of the water, or do not have thermal protection, such as a wet suit or survival suit, stay as still as possible in the H.E.L.P. (Heat Escape Lessening Posture) position with folded arms and crossed legs, floating with your back to the waves.

If two or more people are in the water put your arms around one another in the huddle position until help arrives.

Treatment depends on the severity of hypothermia.

In mild hypothermia the victim is shivering, but coherent. Move victim to sheltered place of warmth. Remove wet clothes. Give warm (not hot) sweet drinks, but no alcohol or caffeine. Keep victim warm for several hours. Use your own body heat, if necessary.

In moderate hypothermia, the shivering may decrease or stop, but the victim is no longer coherent and may seem irrational with deteriorating coordination. Treat same as mild, but no drinks to prevent aspiration. Keep the victim lying down with his torso, thighs, head and neck covered with dry clothes or blankets to stop further heat loss. Seek medical attention immediately.

In severe hypothermia, the shivering has stopped, the victim may be semi-conscious or unconscious. Do not assume he is dead just because he is cold. The saying in the emergency room is: "Nobody suffering from hypothermia is dead until they are warm and dead". Victims have survived 45 minutes or longer under water due to a cold reflex that shunts the oxygenated blood to the vital organs while slowing their rate of metabolism prolonging their survivability. If pulse and breathing are totally absent, start CPR and call for immediate medical evacuation.

Plan ahead! Wear clothing by the "layer" effect. As the weather gets colder, put more layers on. As the weather gets warmer, take layers off. Personal flotation devices, such as life jackets especially for children, are the only ways to survive cold water emersion. Wool, nylon, polypropylene fabrics do not effectively prevent heat loss in cold water. Fleece-lined polartec clothing (Patagonia) is rated equal to 2.5mm neoprene and is comfortable under outer clothing. These can be found in catalogs and marine stores. Carry dry clothing in waterproof bags.

A short rope sling tied to the transom with a foot rest in the loop may assist boat re-entry. A lifesling or harness can help you stay with the boat. Attach a whistle and light to your life jacket to signal for help. Tell someone where you are going and when will you return. More men have fallen overboard with their zippers open. Have a safe boating experience!


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How to Survive a Heart Attack

by Mark N. Monroe, M.D.

Q: So, what is the best way to survive a heart attack?

A: Call 911 because ambulances get priority treatment and enter the E.R. by the back door without waiting.

Heart attacks are the scariest because they are the leading cause of death in the United States. Heart attack, also called a myocardial infarction, is the death of a part of the heart muscle due to a sudden loss of blood supply.

Cholesterol can plug up the coronary artery up to 99%, but it is the blood clot that is the final killer when it completely blocks the artery. The blockage deprives the heart muscle from oxygen. It kills the heart muscle. This lack of oxygen produces symptoms such as shortness of breath, mid to left squeezing pressure chest pain, which may radiate up to the neck, jaw, left shoulder, left arm, and/or upper back, heartburn, and sweating. Death of the heart muscle may also cause an electrical arrhythmia, or irregular heart beat.

Regular beating of the heart is essential to efficient pumping of the blood. Certain arrhythmias, such as ventricular fibrillation, make the heart only quiver and not pump oxygenated blood to the brain. Permanent brain damage or death can occur, unless oxygen blood flow to the brain is restored within 5 minutes. Early heart attack deaths can be avoided if a bystander starts CPR within 5 minutes of the onset of the heart attack. CPR involves applying continuous external chest compressions to make the heart pump and allows airflow except in drowning or choking victims. When paramedics arrive, medications and/or electrical shock (cardioversion) can be administered to restore normal heart rhythm.

An AED (Automated Electrical Defibrillator) automatically analyzes the rhythm and then gives the appropriate electrical shock. Survivability depends on getting the patient to a Chest Pain Center within that first golden hour from the onset of the heart attack symptoms. This allows the physician to possibly save precious heart muscle by either injecting enzymes to eat up the clot or an angiogram to find the obstruction of the coronary artery and open it with angioplasty (dilation by a balloon catheter and/or stent wire mesh tubing placement).

Immediate treatment out in the field includes Aspirin as a blood thinner. 150 mg chewable Aspirin can be placed under the tongue or along the gum as soon as the symptoms start (unless the patient is known to be allergic to Aspirin). Eighty-one mg of Aspirin should be taken daily as a prevention of the blood clot. If Nitroglycerin, a blood vessel dilator, is available, it should be given sublingually immediately to lessen the chest pain. Getting annual physicals by your family physician is absolutely the best way to catch heart disease early before it gets to the point of being an emergency.


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Fatigue at Sea

by Mark N. Monroe, M.D.

On April 28, 2012 at 1:30 A.M. on a moonless night with 8 foot seas and mild winds, four sailors were lost at sea during the Newport to Ensenada Race. None of the three bodies recovered were wearing a life jacket or safety harness. It is the first time in the 65 years of this race that there has been any fatalities. Although the USCG investigation is still ongoing, the search of the debris area (10 miles south of San Diego near Los Coronados Islands and 10 miles off the Pacific Coast of Baja Mexico) has been called off. The San Diego Coroner has declared the cause of death of two of the victims as Blunt Force Trauma. The scrapes and contusions on the victims as well as the total destruction of the 37.5 foot Hunter sloop “Aegean” raises the suspicion of a collision at sea by a large commercial vessel such as the ones that transit that area at approximately 20 knots or 1 mile every 3 minutes. The question arises: Could crew fatigue on either or both vessels have played a role in this tragedy? If so, how could it be avoided and/ or treated?

First is to avoid fatigue of the crew just like avoiding chafe and metal fatigue of the parts of the boat. When off watch, sleep and do not succumb to the adrenalin of racing by small talking with your fellow crew members or drinking alcohol. When on watch especially at night, two pairs of eyes are better than one. Stay warm, eat high protein snacks, avoid seasickness, unnecessary exertion, and night blindness by keeping lights down or use red lights or night vision binoculars scanning the horizon. The COLREGS Rules of the Road state that every vessel is required to maintain a watch by sight and sound at all times in order to avoid a collision at sea. If your boat has radar, turn it on, tune the gain to get the best picture, maintain a watch on it both manually and electronically with at least an 8 mile radius alarm guard zone which gives both vessels about 20 minutes to change course drastically by at least 60 degrees. If the relative bearing of two vessels is constant then they are on a converging course. International Rules also require all commercial vessels greater than 290 tons to have an Automatic Identification System which identifies the vessel, shows its photo if available, as well as its ports of origin and destination, and its current location, speed, and course. The Aegean’s AIS stopped working at 1:30 A.M. I wish to convey my condolences to their families. My next article will be an update on seasickness including which medications and methods do not cause drowsiness.


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Accidential Electrocution

by Mark N. Monroe, M.D.

Q. I was accidentally shocked in my right hand while fixing 110v system on my boat. Now my right arm is numb and tingling at the same time. Should I be concerned?

It is common to become accidentally shocked or electrocuted. About 400 die each year from accidental electrocution. Electricity needs two things to function: a power source and conductor. The conductor could be an insulated piece of wire, metal or you. Wearing latex rubber gloves could have protected you from the shock. You should always turn off the source of electricity before working on the electric system. Test the wire with volt ohm meter to make sure that electricity is turned off. The electricity can enter your body through a small spot like on your hand and expand up your arm causing muscle and/or nerve damage. The damage could be anything from mild tingling or 2nd or 3rd degree burns. It could be temporary or permanent and if the electricity crosses your heart, it can even result in a cardiac arrest. The lower the voltage, the more current will be needed to do the damage and vice versa.

If you get numbness and tingling, sometimes desensitizing the nerve by rubbing it on your clothes will cause nerve pathways to generate returning sensation. If there are blisters, then you need to be treated for burns or referred to emergency room if you don’t know how to treat burns. If the heart is affected, such as chest pain or arrhythmia, then call 911 immediately and start CPR right away. If there is nerve pain involved and the symptoms don’t go away quickly, a neurologist could prescribe a nerve pain medication. Your family doctor is the best source of information, treatment and referral, if appropriate.


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Complex Regional Pain Syndrome (CRPS)

by Mark N. Monroe, M.D.

Q: I fell down the steps on my boat and broke my hand and wrist requiring surgery to fix it. Now I have severe pain, swelling, and mottled skin there. My doctor diagnosed me with CRPS and referred me to a pain specialist who wants to give me nerve block shots, but I don’t want anything so invasive. Can you tell me what is CRPS and what else I can do?

A: Complex Regional Pain Syndrome (CRPS) can become a chronic progressive disease with severe pain, swelling, and local skin color changes. The key is early diagnosis and treatment. The cause is trauma or surgery to an arm or leg. There are two kinds of CRPS. Type I is called Reflex Sympathetic Dystrophy (RSD) which does not have demonstrable nerve damage. Type II is Causalgia which has obvious nerve damage.

Early multimodal treatment is the key to successful management and even possible resolution of the disease. Start with topical treatments such as Flector patch or Lidoderm patch or DMSO 50% cream. Physical therapy by a physical therapist who specializes in hands can help greatly. He can set you up with a TENS (Transcutaneous Nerve Simulation) unit which blocks the transmission of the pain up to your brain. Elevation of the injured part will help with swelling.

Some patients get very depressed from pain which could lead to insomnia. Anti-depressants are very helpful for these patients. Anti-inflammatory medications such as ibuprofen or naprosyn will help to reduce inflammation, pain and swelling. Non-narcotic analgesic such as tramadol as needed can help relieve the pain.

If non-invasive pain management is not successful, then the next step would be the Nerve Block injections given by a board certified anesthesiologist who specializes in pain management.

As always, your family doctor is the best source for pain management and referral.


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Norovirus Outbreak in Southern California

by Mark N. Monroe, M.D.

Q: On 1/24/13, Janet Kwak on the NBC 11pm evening news talked about The Norovirus Outbreak in Southern California. Would you please tell me what it is, its symptoms, and treatment/prevention?

A: In a previous article, I wrote about the Norwalk Virus whose name has now been shortened to Norovirus. Although it first started in Sydney, Australia, it spread quickly through cruise ships and vacation resort hotels. Now, those vacationers are bringing it back home to Southern California as well as the infected crews passing it on to other cruise ships around the world. The virus is highly contagious with as little as 20 viral particles sufficient to spread it. Each episode of diarrhea or vomiting can put out millions of these viral particles. Prevention is best by the crew washing hands frequenting especially after going to the restroom or before preparing/eating food, disinfecting bathrooms with bleach using latex gloves, masks, and goggles and letting it thoroughly dry for 24 hours before usage by uninfected people.

Most symptoms are mild and self limiting such as vomiting and diarrhea so Norovirus is underreported. However, the immunocompromised patients such as the very young or old, smokers, insomniacs, malnourished (i.e., dieting, not taking vitamins), fighting other infections such as the common cold, or on prednisone or other immunocompromising treatments (i.e., Rheumatoid Arthritis, Lupus, COPD, etc.) are more prone to getting dehydration requiring inpatient intravenous fluids and supportive care. Outpatient care includes:

  1. oral hydration (i.e., Gatorade, Pedialyte, and/or chicken rice soup) 64-128 oz/day
  2. BRAT diet for diarrhea (Bananas, Rice, Applesauce, and Toast)
  3. Antiemetic to stop the nausea and vomiting ( i.e., compazine, meclizine, ondansetron oral disintegrating tablets)
  4. Antispasmodics to stop the diarrhea and painful abdominal cramps (i.e., Imodium A/D, Lomotil)
  5. Plenty of bed rest with a restroom nearby
  6. Close follow up by your family physician


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Rope Burns

by Mark N. Monroe, M.D.

Q: I burned my hands from towing the dinghy while holding the dinghy’s painter line in my hands. Now I have painful blisters on both hands. What did I do wrong? What should I do now to treat the burns?

A: Next time, tie the line to a cleat and never hold it in your hands. Recently at an elementary school, two teams of girls were having a tug of war with a rope. Not only did one girl lose 2 fingers from coiling the rope around her hand, but several participants suffered friction rope burns as well. It does not take a lot of force to produce traumatic injuries to fingers and hands.

I personally have suffered similar friction burns on my hands once. This taught me an important lesson to always use sailing gloves to protect my hands against chafe (friction) such as when anchoring, raising/lowering/adjusting sails or dinghy or docking lines. The friction produces heat which can burn the skin. The burn can be a minimal first degree burn like a sun burn or a moderate second degree burn producing blisters. Third degree burns where it is deep past the skin is rare. Your intact skin is also your best protection against infection as burnt skin is more susceptible to infection.

Initial treatment is putting your hands under running cold water and washing them. The cold water will also help relieve some of the pain as well as taking an ibuprofen can help if you are not allergic to it. Pat dry the burns gently with a clean paper towel or sterile gauze.

Do not rub! Applying aseptically, with gloves and a sterile tongue depressor, topical burn creams such as silver sulfadiazine 1% cream will not only help relieve the pain but also the sulfur antibiotic component will help prevent/treat an infection as long as you are not allergic to it.

Do not put butter or grease on a burn as it will not relieve the pain or infection. Next, apply a Telfa Ouchless Nonadherent Dressing from your first aid kit.

Do not use any adhesive tape as this will produce pain when it is time to remove it. The cream and dressings have to be changed twice daily for a week for nondiabetics. Diabetics are poor healers and take twice as long to heal. Elevate the injured hand(s) above your heart level so as to reduce the swelling. Less swelling means less pain.

Contact your family physician as your best source of addition advice including but not limited to debridement of necrotic tissue/blisters but do not debride it yourself so as to prevent infection. Please keep your tetanus shots up to date every 10 years as well.


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Sholder Injury

by Mark N. Monroe, M.D.

Q: On the recent cruise to Avalon I was jumping off my boat’s swimstep while holding on to it. I felt excruciating pain in m shoulder and thought I have dislocated it. When I went to Avalon clinic, the doctor told me I have a Rotator Cuff tear after he x-rayed it. What is the Rotator Cuff Tear?

A: The shoulder is a ball and socket joint that is held together by the capsular ligament and four muscles and tendons: the supraspinatus on top, the subscapularis in front, infraspinatus and teres minor in the back and bottom. This provides stability to the shoulder. The muscles provide the ability to rotate and form a cuff around the head of the upper arm humerus bone. Trauma, whether acute or chronic, causes the injury to shoulder:

Rotator Cuff tear is an inury that tears a rotator cuff tendon that has been weakened by age or by wear and tear. Rotator Cuff Tendonitis is inflammation of the tendon due to repetitive overhead use of the arm such as throwing. Rotator Cuff Impingement Syndrome is a pinching of the supraspinatus endon between two bones. Adhesive Capsulitis (Frozen Shoulder) is not using the shoulder due to pain and causing loss of range of motion thus letting scar tissue settle in. Bursitis is inflammation of the lubricating sacs that lubricate the tendons.

The most important thing is to see a medical professional for a thorough examination. By performing some in-the-office tests, such as range of motion, painful arch test, tender trigger point, your doctor will determine if further tests such as x-rays, MRI (if no pacemaker), and ultrasound, need to be ordered.

Treatments include:

  1. RISE – Rest, Ice, Sling, and Elevation.
  2. NSAIDs – Non Steroidal Anti-inflammatory Drugs such as naproxen or ibuprofen with food (if not allergic to it). The pain meds may include acetaminophen or narcotics.
  3. Cortisone injections are the strongest anti-inflammatory medicine that reduce inflammation thus leading to less swelling and less pain.
  4. Arthroscopic surgery done by the orthopedist through three small ¼ inch incisions for the fiberoptic camera and tools to confirm the diagnosis and repairing the tear.
  5. Open surgery through a large incision where the torn tendon can be re-attached to the bone using sutures and stainless steel anchors.
  6. Isometric exercises using opposing muscle groups to maintain muscle tone right after the surgery.
  7. Physical therapy usually 2 weeks post-op and lasts 6 weeks to regain full functionality of the shoulder joint.

Your family doctor is the best one to advise you on all the above.


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