How To Train

By Joseph Accursio NP


Let’s have a discussion about another subject fraught with peril and misinformation – exercise. There are as many different opinions regarding exercise out there as there are regarding diet. On top of that, every month each of the millions of fitness magazines on the planet publish the next full-body-in-just-four-minutes-a-day-routine-to-end-all-routines exercise plan. Add in what’s trending and anecdotal evidence from friends and acquaintances, and you have very little guidance in selecting a program. 
Where to start? With discipline, of course! Like dietary changes…and any change for that matter, deciding to train regularly is a commitment. Make the time, make the plan and make the exchanges, because there are trade-offs. If you’ve made it this far, congratulations. Now set down your ideas and get your support system in place. A support system must enable you to achieve your goals. In other words, this isn’t just a cheering section. Its someone or something that can pick up the slack for you as you get started. Proactively eliminate your barriers and it will make things exponentially easier for you when you hit a bump in your road.
On to the actual training part - How do we choose an exercise regimen? 

Here are a couple of bullet points:
1. It must be something that you enjoy. Making your body move in new and unusual ways, especially if you’re not accustomed to it, is hard enough. If you hate running and you’re planning on a new 5-mile four-in-the-morning daily run, STOP THIS IMMEDIATELY. 
2. Take it SLOWLY. Literal baby steps, especially if you’ve not previously trained. Working out with great intensity and then being so sore you can’t walk for the next week is a major motivation killer. Try ten pushups, ten squats and ten sit-ups today. Tomorrow, make it eleven. Increase it one per day, and before you know it, you’re up to a significant number of reps. 
3. DON’T measure progress day to day. Don’t look at yourself daily in the mirror, or count calories, or measure your body fat. This is the road to discouragement. Even though this is an inch-by-inch journey, I recommend you don’t measure physical progress for many weeks yet. Skip the mirror and the scale. Surprise yourself…you will pick up on the little clues along the way.
4. DO keep a log or journal; exercise routines must be systematic. So in this way, you should track your progress. Making it up as you go is also a path to discouragement.
5. DON’T get caught up in trends. Pick something and go with it. The people on the magazines are airbrushed. Pick something, make progress, adjust every 8-12 weeks as you fine tune your focus.

That’s it, in a nutshell. 
And which exercises give the greatest bang-for-your-buck? A common rule of thumb is “cardio for length of life, weightlifting for quality of life.” But this largely depends on your goals. 
After completing a master’s in Exercise Physiology prior to medical school, a physician friend of mine answers the what-kind-of-exercise question by saying, “Just move!”
What about exercise intensity? Another good rule is this - do as much as you can, for as long as you can and gauge your exercise by how you feel. Stress is good, so don’t be afraid to push it! But, if you’re intensity is causing your workout to be very short or painful in any way, then you’re overdoing it. 
Also, despite evidence that indicates “fitbits” and things don’t add much to your routine, another good rule is: if it helps you mentally to stay on track or be motivated, go for it. Some people are heart rate watchers, some are not. Some like to count steps, others do not. As long as you’re not putting any stock in these devices doing the work for you, then they’re ok for motivational purposes. 

Of course, this post wouldn’t be complete without the general disclaimer: clear your exercise program with your primary care provider before you start, and know the signs of potentially serious health problems with your heart or lungs. 

Sprains, Strains and Automobiles (not really)

By Joseph Accursio NP


Is getting more active part of your resolution for the upcoming New Year?  If your goals include a new work out routine, running, playing and taking risks, then it's important to be mindful of potential injury to your joints. Here’s a quick guide to injury identification, initial treatment, and when to seek a higher level of care. We will discuss the lower extremity joints – knees, ankles and feet.


A brief classification scheme before we begin: 

Strains – injuries to a muscle or a tendon (which connects muscle to bone). Unless there’s obvious deformity from a complete tendon or muscle tear, these injuries present with localized soreness that gets a little worse before it gets a little better, maybe some mild swelling, maybe some mild bruising, and fairly rapid recovery.

Sprains – injuries to ligaments (or bone-to-bone connectors). These injuries are generally more severe than strains because ligaments recover more slowly and, dependent on how serious the sprain, there can be some temporary or permanent laxity leftover. These injuries present with fairly localized soreness and swelling, bruising and there may be a feeling of instability at the site of injury. A sprain is also dangerous because the load meant for the injured joint will shift to another structure, potentially causing strain and soreness in another location.

Contusions – another term for bruising. There are deep and superficial contusions, though these will generally resolve without complication after initial pain, swelling and darkening of the skin at the site (note that healing times for contusions or any injury may be increased with the use of anticlotting drugs or blood clotting disorders).

Fractures – broken bones. Treatment will vary dependent upon the site, type of break, precise location of the break and the age and health status of the injured person. 


First thing to note, most injuries that occur without a significant mechanism (such as a fall from a height, high speed injury or crash of some sort) are NOT going to be serious, and will respond well to RICE (rest, ice, compression and elevation). Even in the case of serious injury, RICE therapy is going to be the initial treatment, along with pain control, splinting and expert consultation. 

How then do we determine severity of injury? There are some rules out there that clinicians use to decide whether or not an x-ray is necessary – the Ottowa rules. These are easy to apply, BUT can be made difficult in the case of acute (“right-now”) injury, because pain and swelling inhibit the ability to make a determination. Here are the rules in short, for each joint:

Ankles – if either of your “ankle bones” hurt AND you have well-localized bony tenderness at the site of injury, you need an x-ray;

Feet – if the middle of your foot hurts AND you have bony tenderness on the outer (lateral) aspect of your foot or bony tenderness at the navicular bone (extra bone or piece of cartilage located on the inner side of the foot just above the arch), you need an x-ray; 

Knees – if you’re over 55 years old, if you have well-localized pain in your kneecap, if you have tenderness on palpation below the knee at the lateral (outer) aspect of your leg, or if you can’t bend your knee more than 90 degrees, you need an x-ray. 

A general rule for all joints: if you can’t bear weight now and in the urgent care or emergency room for 4 steps, you likely need an x-ray.

Again, these criteria are great but the elicited tenderness has to be when pushing on a bony surface, not on swollen and bruised skin.
Recapping, most injuries are not severe and will respond well to RICE as discussed above. When you ice something, BE DILIGENT! That doesn’t mean 10 minutes and you’re done. To be effective, ice 20 minutes on, 20 minutes off, as much as you can stand it for the next 48 hours. Take Tylenol or ibuprofen as directed if you need it. Give RICE a try for 5-7 days. If you’re getting better, keep on. If not, follow up with a doctor. Remember, if ever you are unsure of how to proceed after a non-emergent injury, you can consult one of BitMED's physicians for recommendations!

One more very important point – Don’t return to activity until you’re 100% absolutely-like-brand-new recovered. An injury is one thing, but compounding a second injury on an unstable structure can cause big problems. It’s not worth the risk.

Why Eating Breakfast Boosts Your Health!

By Mike Polich NP


Looking at the year ahead, do you want to make 2018 the year you focus on your health? Wellness goals are admirable throughout the year, but too often well-meaning people make a common mistake that sabotages their efforts: they skip breakfast.

It's a daily choice that millions of people shrug off as "no big deal", but research proves breakfast is an important component in how you feel throughout the day. Fueling up solely on java or energy drinks may perk you up momentarily, but it doesn't do the trick long-term.

Consider these five reasons why breakfast boosts your health and should not be ignored. Breakfast:

1. Awakens your metabolism
When you eat breakfast, you "break the fast" from your sleep periods and give your metabolism a wake-up call. When you sleep, your metabolism slows and you burn fewer calories while you rest. By eating a nutritious breakfast, you are sparking your internal engine so it burns calories and gives you more energy throughout the day.

2. Helps you focus
Hunger can make people irritable and it's hard to focus on work when your stomach is grumbling. By eating a balanced breakfast of fat, protein and fiber, the food is processed into energy, allowing you to feel fuller longer.

3. Steadies the burn
When you skip breakfast, the body panics for nutrition, so come lunch time, you tend to overeat. This in turn overwhelms the metabolism and you end up with peaks and pits of energy throughout the day. For steady energy and efficient calorie-burning, eat a nutritious breakfast and other meals on schedule.

4. Encourages healthy choices
People who eat breakfast tend to make healthier choices throughout the day. According to, "People who eat breakfast tend to eat a healthier overall diet, one that is more nutritious and lower in fat. In contrast, people who skip breakfast are more likely to skip fruits and vegetables the rest of the day, too." Try starting the day with 100-calorie multi-grain English Muffins.

5. Sets a good example
When you eat breakfast, it sets a good example for your family. Plus, sitting down to a nutritious meal is a positive way to start the day together. You're helping your kids form healthy habits that will benefit them with increased focus and energy at school, ensuring they can do their best academically.

So don't skip the most important meal of the day! Furthermore, studies of children and adolescents have shown that those who skip breakfast are apt to be overweight.  Questions about what and when to eat?  Talk to your doctor or one of the providers at BitMED!

Getting Better Sleep

By William Jantsch MD

Sleep is a remarkable phenomenon that is not well understood, but definitely necessary for proper mental and physical function. Most adults need between 7.5 and 8.5 hours of sleep every day. The consequences of not getting sufficient good-quality sleep are severe, and can include depression, chronic fatigue, headaches, high blood pressure, muscle aches, and an increase in risk of heart disease and stroke. 

Many people have no trouble sleeping; such people fall asleep easily, go through multiple cycles of REM sleep (or “rapid eye movement” sleep, when dreams occur), and wake up feeling refreshed and invigorated. Unfortunately, many others will have trouble falling asleep, staying asleep, or will not sleep efficiently, and will roll out of bed in the morning just as tired as when they went to bed.

People with poor sleep quality would be well served to consult a physician, who may be able to determine whether there is physical or psychological reason for poor sleep. One of the most common conditions leading to poor sleep nowadays is Obstructive Sleep Apnea, a consequence of severe snoring which causes a person to choke during the night, temporarily interrupting breathing.

Prior to or in conjunction with a physician’s evaluation, there are steps a person can take in order to have a better chance of good sleep. These measures as a whole are referred to as “sleep hygiene”, and recommendations follow:
a. Have a regular routine: Go to bed at the same time every night, and try to get up at the same time every morning; Try taking a warm bath or shower prior to going to bed. Meditation or other quiet activity right before bedtime may help you be relaxed and calm.
b. Avoid naps: Napping can lead to fragmentation of sleep patterns at night.
c. Foods, beverages, and medications to avoid: Alcohol is the worst offender- a few drinks may help you get to sleep, but the process of metabolizing the alcohol will cause you to be awakened in the middle of the night. Also, avoid decongestants and other cold medications. Coffee and tea should be enjoyed only in the morning, not after noon.
d. Things not to do in bed:
     1. Stay awake: If you just can’t sleep, after 5 minutes get up and sit quietly in a chair in the dark. Don’t turn on the lights and start reading or going on the computer.
     2. Eat
     3. Watch tv
     4. Use a tablet or computer with a bright screen: the bright blue lights of a computer or tablet screen can fool your brain into thinking that it is still daytime.
e. Get regular exercise: Try not to exercise within 8 hours of going to sleep at night.
f. Have a quiet and comfortable sleep environment: Keep the bedroom cool and quiet; consider getting a “white noise” generator if there are extraneous sounds around you. Don’t let your pets interrupt your sleep by jumping on the bed. Make sure your mattress is comfortable.

If you have further questions, ask your primary doctor, or consider chatting with one of the doctors on BitMED.

Good night, and sleep well!

How To Eat II

By Joseph Accursio NP

“Let food be thy medicine, and thy medicine be food.” Hippocrates

Continuing from a previous post, the idea behind this article is to provide a streamlined way to think about nutrition and what to eat. There are a seemingly infinite number of dietary tips and tricks and methods out there, but if we’re going to make changes and think about things differently, then we have to make it simple and useful. Without further ado, here is my personal way to view eating:

First things first, we need to get the “d-word” out of the way. Discipline. Changing your eating habits on a permanent basis is unpleasant. There is no way around this. That’s why a proper perspective and going into a change with both eyes open is crucial. You’ll have times of struggle, weakness and discomfort. But, as the old Rocky IV song goes, “it’s you against you, the paradox that drives us all.” So then, show your appetite who’s boss!
A pivotal part of discipline is planning ahead. If you try to wing it in times of stress, you will fail. Don’t stare temptation in the face - plan for it, then run from it when it comes- because it will come. The more you do on the front end, the higher likelihood of your success. 
With that groundwork laid, onto the actual food part: 

There are three sources of fuel that the body can burn in order to stay alive – carbohydrates, fats and proteins. Anything that doesn’t fall under those categories is a filler, a fiber, water, or a nutrient of some kind (like vitamins and such). 
Carbohydrates are, for all intents and purposes, sugars. From white stuff in a packet to broccoli stems. There are “simple ones” and “complex ones,” which relate to a concept called glycemic loads in conjunction with what else you’re eating at the time – but let’s not make this a chemistry lesson. 
The low carb diet has long been a staple of discussion for fad diets, but keep this in mind: though your body can make sugar from other sources, you need some carbs on a regular basis for your brain. If you don’t take in something carbohydrate, you will feel a little mentally foggy and irritable.
The carb bottom line: get your sugars from fruits, vegetables and high fiber grain breads. And there is almost never a justification for things like Gatorade. Unless you’re a successful marathoner, in which case you’re not likely reading this post.
Next up is proteins. Protein is the building block of functional tissue; think of it as more of a structural component. What you’re made of. Your body can use proteins to make carbs, but the process is also more drawn out and causes the same mental fogginess and lack of energy.
Protein is an important fuel source, but unless you’re (again) a marathoner in training, the super high protein diet is overrated and unnecessary. The human body generally turns over about 80% of the protein needed on a daily basis, which means most protein that’s broken down is recycled and reused. The most important two things about protein are the essential amino acids (i.e. proteins that your body can’t make) and the fact that proteins make you feel full. 
Finally we have fats, which tend to get a bit of a bad rap. Fats are long term fuel supplies. Though your body needs some carbs to burn fats, fat is the best type of long duration energy. Fatty meals are higher in calories because fat is calorically dense. Here’s a positive trend on the rise – the return of fat as significant source of food intake. After decades of an errant cultivation of fat-fear and high sugar replacement foods, scientific research is yielding data that healthy dietary fats (i.e. NOT foods in a wrapper) are A-OK. Dietary cholesterol guidelines are on the way out, and the idea is that it was the sugar all along, not the fat. There are many bridges to cross yet on this one, and surely there is and will be an overzealous “fat” trend that acts like many other trends, but keep an eye on forthcoming fat-related findings. 

So in summary, take the following points:
1. Food is fuel, not entertainment. Be disciplined above all.
2. Carbs, proteins and fats. That’s all there is. And there are healthy varieties of each.

Two more things to note – 
No matter what you’re eating, if you’re eating too much of it, you will not maintain a healthy weight or energy level, and you’ll be disposed to mood swings and mental changes. This obviously doesn’t help you maintain that discipline. Don’t gorge. Leave yourself just a little bit hungry.
Finally, the most difficult point in today’s culture – don’t eat out of thin plastic packages or fast food wrappers. Make it a rule and stick with it. The stuff that comes out of this packaging is SUPER calorie dense, very high in sugar and has little nutritive value. Think of it as waste product and avoid at all costs. 

Fever – how do you do it right? I am feeling hot tonight!

By Allison Godchaux, NP

Fever – how do you do it right?  I am feeling hot tonight!

Fevers: something we or our friends and family have had at one time or another.  It should be easy to figure out whether or not someone has a fever.  It should be pretty straightforward determine this, but it’s not.  So, let's spend a moment to talk about it.

What is a temperature?  To make it simple:

FireShot Capture 254 -  - file____Users_simonapostolski_Desktop_fever__how_do_you_do_it_right.pdf.png

Unfortunately, taking a temperature isn’t so precise that we can say to specifically add or deduct 0.5 or 1.0 degrees Fahrenheit (F) or 0.3 to 0.6 Celsius (C).  If a patient is sick, we don’t just rely on the number on the thermometer, we also look at the patient's other symptoms as well!  

Other factors to consider when taking a temperature:

1.     Type of thermometer you are using.

-       Ear (Tympanic) – the amount of earwax in an ear can lower the number you get.  A narrow ear canal can also lower the number.  Don’t try and push it in, either!

-       Axillary or armpit – if the thermometer isn’t positioned correctly, the number you get will likely be lower than it really is.  Make sure you place the thermometer deeply into the center of the armpit, then lower the arm on top of the thermometer next to the body, holding it firmly.

-       Orally – if you have had anything to eat or drink within ½ hour of taking your temperature, it may falsely lower or raise the number depending on what you have consumed.

Remember: No drinking or eating (if you can avoid it) up to ½ hour of taking an oral temperature!

2.     Consider the age of the person whose temperature is being taken when choosing the appropriate thermometer type.  Below is a diagram that makes it simple:

FireShot Capture 255 -  - file____Users_simonapostolski_Desktop_fever__how_do_you_do_it_right.pdf.png

 Common questions medical providers are asked in regard to taking temperatures:

How long should I take the temperature?  Unless your thermometer beeps at you to indicate when to stop, leave it in place for 3 minutes.

Should I compare the temperature in two different areas if I am not sure I am right?  Not necessarily, and it isn’t necessary to double-check with different types of thermometers.  Find a thermometer you like, and get used to using it. Try it on your family members.  When you need to use it, you will be comfortable using it, and will have faith in the numbers you get.

I prefer a pacifier thermometer for my baby, what do you think of those?  Honestly?  I love them! …I love the idea of them anyway.  The problem is, when you have a sick kiddo, they usually don’t want to keep the pacifier in long enough to get a good reading.  Unless your experience of this is different than mine, I would stick with a temporal (forehead) or rectal thermometer.

I don’t want to use a rectal thermometer- I’m worried that I will push too far or hurt my baby!  I absolutely understand.  When you use a rectal thermometer, use a little Vaseline or petroleum jelly (same thing) on the end of the thermometer, then insert it a ½ inch into the rectum.  I insert it with my thumb and index finger and use my other fingers to brace my hand and the thermometer against the baby’s bottom so as to not push it in too far. If your thermometer is the type that beeps at you, wait for the beep, and then remove thermometer. Don’t forget to read it immediately!  If it isn’t the kind of thermometer that beeps at you, then hold it in place for 3 minutes, and then take out the thermometer.

I was told that I should never use a rectal thermometer orally, even if I wash it really well.  Is this true?  As a matter of safety, it is true.  I am sure that you do wash it well, but we don’t want to take any chances.  If we were to transfer some bacteria from the rectum accidentally, we could make our sick child even sicker.  Good question!

If you have any other questions or concerns, don't hesitate to log on and ask your BitMED provider!