Thursday, April 26, 2012


Imagine that you are blindfolded and driving 55 miles per hour.

It will take about 4.5 seconds for you to travel the length of a football field.

4.5 seconds is the average amount of time it takes for people to look down and check their phone for a message.

Distracted driving is not just a problem with youth - it is a problem for everyone. From those who are pedestrians, not watching as they cross the street (because they are texting or have their hearing impeded by ear buds) - to drivers who just 'look down for a moment' and end up in a motor vehicle accident, distracted driver is an avoidable cause of morbidity and mortality.

If it took no attention to drive, then perhaps brushing your hair, changing the radio channel, talking on the phone and picking up a phone to text, might not be a big deal. But considering the several ton missile most cars are and the amount of erratic driving that occurs, safety means unplugging and expecting crazy driving, so that you don't end up in an accident or worse.

The national site has a number of powerful stats and even more powerful videos from across the country that brings home the message about distracted driving. One that I found very interesting was a young woman from NJ whose friend was killed by a distracted driver and who admitted that she needed a reminder to not be distracted (so she put a picture of her dead friend on her dashboard)
Here's one story - Ashley age 16

How can you prevent distracted driving?1. Stow your phone in an inaccessible place (purse, glove compartment.)
2. Turn your ringer off until you have arrived.
3. Consider if you are tired or having difficulty concentrating and pay extra attention while driving. (phone off, tunes off)
4. Anticipate that other drivers will be distracted. Is that driver weaving over a line while driving? Might be alcohol but more likely is texting!
5. Anticipate pedestrians texting and being unaware to sound (with ear buds) as they cross the street.
6. Anticipate bicyclists are equally distracted.
7. Help friends and family eliminate distractions. For example, have messages that signal friends and family that you have to concentrate on driving ('have to go now, traffic is tough.")

CLINICIAN NOTE: Due the prevalence of this problem, clinicians should screen all patients who come to them with injury (pedestrian, motor vehicle, etc.) and ask if they were texting or listening to music (with ear buds) when the injury happened.
In Philadelphia in 2009, a talented young school teacher was killed while running in Fairmount Park because a huge branch (30 feet) fell from a tree that was 50 feet or the equivalent to five stories.
Since she could not hear due to loud music and ear buds, she did not hear it snap and fall. The branch struck her, broke her neck and severely injured her head and limbs. 


Urinary incontinence (UI) in older women is an under addressed problem by patients and clinicians. In general, women's rates of UI are twice that of men and are a problem for 80% of institutionalized elder (e.g. living in nursing homes.) Because women don't bring it up (less than half in some studies) and clinicians don't screen, clinicians miss the more than one out of three women with this condition. A woman's lifetime risk is 30-60% This 'miss' is incredibly expensive. It is expensive in terms of quality of life (women have greater isolation, depression, anxiety, falls/fractures as well as bedsores and admission to long term care facilities) - but it is expensive in care delivery. Excluding cost of long term care facilities, some estimates are up to $20 billion dollars (about 1/3 are for absorbant products alone)

More than one in five young women have IU, for middle aged women the range is about 42-56 percent and in elderly the number is about 75%. With boomers, booming, we will see more and more of IU. Clinicians and patients alike need to be more aware and discuss this.

So, the breakdown of types of IU and urine leakage include functional (mobility or access reasons); stress (pressure overcomes pelvic muscles); urgency (bladder signals urination is needed and releases urine); mixed reasons and overflow (this occurs more in men than women but is often seen in neurological conditions or as a result of medications). Overactive bladders refers to bladder wall hyperreactivity that creates urgency (but leakage does not occur) It is also important to recognize that the urinary incontinence can be associated with rectal or fecal incontinence, so even if not identified by the patient, elements of rectal tone should be included in the evaluation.
Women at higher risk include - ethnicity being Caucasian, being postmenopausal; having multiparity; having a higher BMI, using hormonal therapy; having Diabetes/Sleep Apnea/CHF; having neurologic diseases (Parkinsons, MS) An interesting point I came upon is that women with two or more of the following (DM, HTN, Back Pain, Arthritis, COPD;  hearing/visual deficits; cognitive deficits; parkinsons) are also a higher risk.

The pelvic muscles are an amazing grouping of muscles. It is extremely rare in a human body to have a muscle group simultaneous contract and relax in a coordinated fashion. That's what the pelvic floor does. That is why you can void without deficating and deficate without voiding. It is also why the coordination can get confused - post hysterectomy or birth or trauma.

In older women - more than 50% have mixed UI. So it is important to assess if it is stress or urgency predominant in order to treat.  One item jumps out when reviewing contributing factors of incontinence and that is the functional status and the ability to void.

We have no practice standard to assess functional strength of pelvic muscles (and maybe we should!!) So if pelvic floor muscles are weak, women will have IU. How we hydrate and when we void are another important element.

Many people only urinate when they feel they can't hold any more urine and are very uncomfortable. The 'waiting until your eyes turn yellow' approach is NOT bladder healthy. 

Retraining on intake and urination is important in addressing incontinence and bladder diaries are used to guide this. Some women have to schedule getting up and voiding in their daily calendar to remind them and that is one strategy that can work. Another important piece of information about hydration is that is you are dehydrated, concentrated urine is an irritant and can contribute to the sense of urgency!
A reversible element a clinician must screen for is urinary infection (taking into consideration that asymptomatic bactiuria should not be treated.) Functional status is also important. If gait is unsteady or arthritis is severe and transfers take a long time, incontinence can results. If there are sensory deficits (vision, hearing) o if it takes far longer to get to the toilet than is planned, women can have leakage. Sometimes, soft cognitive deficits (which can be hidden) are the reason why strategies to address incontinence don't work.

Medications also play a role - these include caffeine and alcohol as well as diuretics.
As seen in the chart, multiple medications can have a urinary effect. It is reasonable to consider that if a patient has polypharmacy, she should be screened for incontinence.

CHECK IT OUT - HOT OFF THE PRESSES APRIL 2012!! Info for clinicians and consumers here: