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When You Hear Hoofbeats

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Discusses the pragmatic approach to ruling out issues and conditions using a tried and true logic that applies across the board

Specializes in Whole Health and Behavioral Health.

Common-Sense Approach When Ruling Out Issues And Conditions When Caring For Patients

When You  Hear Hoofbeats

Listen for Horses... Not Zebras

In all aspects of life, a wise adage of "when you hear hoofbeats, think of horses and not zebras" truly applies. If you are not familiar with this approach to observing and responding to problem-solving it’s worth exploring.

Health care, and to a large extent the rest of the working world, is focused on listening for the zebras - that is, looking for the pathology, the disease, the exotic condition, something to diagnose. Rather than taking a simple, practical and common-sense approach to assessing cause and effect and practicing health care, we continue to associate the hoof-beats with zebras, or the exotic pathology we have all been trained to look for.

Common-Sense Approach Beginning to Disappear

This meaningful approach to care has been lost within this modern “expert medicine” era. We can even see today that this common-sense approach is even beginning to disappear from "alternative" health care practices, as well. Using many forms of supplementation or non-toxic treatment modalities are often used in place of drilling down to the causative factors in a patient’s symptom complex.

For Example...

Here is an example from one of my recent office visits with one of the patients. A very gifted, physical therapist, someone I have had treatment from myself, called upon me after having intractable muscle pain for a week. He could not lie down, could not sleep was in great discomfort, and was also concerned about what this could mean. He had spoken to a wide variety of practitioners who normally deal with musculoskeletal conditions and at the end of his exploration was still in pain and becoming rapidly more concerned. His doctors and practitioners were looking for the dysfunction or pathology that was causing his symptoms and treatments were not working.

When this happens to us we start to think, "do I have something really wrong with me?", if you're older you think "this must be what getting old is about", or if you are an active, healthy person who takes care of yourself you might ask, "how could this be happening to me, I take care of myself." This individual said he called me because he "didn't know where else to turn" to understand his pain and condition and isn't this what I did in my practice – look at the big picture and figure things out about the cause and effect?"

Start with the Basics

Being a Whole Health educated practitioner and patient educator, I started with the basics:

  • What specifically had he been doing prior to this onset?
  • What had he been feeling or avoiding feeling before this happened
  • Where is the specific discomfort?
  • Has he experienced this before and under what circumstances
  • What makes it feel better?
  •  What makes it feel worse?
  • Did he experience any other symptoms along with this pain?

He explained that he just joined a gym and was working out for the past week, but that he wasn't doing that much exercise to cause this discomfort and it wasn't just in one muscle, it was all over his body. He is in very good physical condition so the idea of mild exercising causing this full body pain didn't resonate.

He reported that he hadn't changed his diet, work habits, taken any unusual supplements, changed beds, changed shoes, or had any upset or stress over the past week. He tried a series of natural remedies and treatments to no avail. He was both personally and professionally stumped and so were the practitioners he had spoken with about his pain.

Having been called by several of my patients, the "Sherlock Holmes of Whole Health", I knew the task at hand was to find out the missing piece of information that would unlock the cause of the problem. Looking at the 5 Aspects of Whole Health ™ - the physical, environmental, chemical and emotional possibilities of what could cause this is where we started. We discussed his new membership at the gym. Logic told me that there was something connected to his activities at the gym that was the causative factor in his pain experience because it was after joining the gym that his pain began. It was just a matter of putting our finger on it.

Having suffered chronic back pain myself, I have been a fan of John Sarno, MD, who practiced from a causative perspective targeting the emotional roots of back and body pain. He had cited much research and evidence-based information on the subject but did not take a whole-person perspective, which is how we approached this patient.

After a few minutes of detailed review, one factor that surfaced seemed the right solution to the problem. After his workout, he went for a swim in the gym's pool.  After questioning him about the swimming experience, he shared that the pool was heavily chlorinated and he could tell because the water made his eyes burn.  Interesting and a major clue.

Now some of you who are practitioners reading this might think, "Ah-ha, he has a virus from the pool water", or “he swallowed pool water and had a bad reaction, or “his immune system must have had a toxic reaction to the chemicals in the pool". Sorry, but no cigar - these are all zebras.

Having comprehensive, evidence-based, health information and understanding of the How and Why of body function is critical in truly serving our patients/clients and being able to empower them with the knowledge they need to take control of their health.  Demystified health information is absolutely critical to empower your patient to take control and retain control over their health.

What does chlorine do to our body? It draws out minerals, most importantly calcium and magnesium. Because chlorine molecules have double negative bonds it is wildly attracted to double-positive bonds, as found in calcium. What minerals are significantly involved in muscle function?  And, what minerals are likely to be diminished with repeated exposure to chlorine – Ca and Mg!

I recommended that he go to Whole Foods or CVS and purchase a calcium and magnesium powder, take a dose am and pm over 2 days, and see if that helped. I received an e-mail about 24 hours later with the subject title "WOW" - it dramatically took away most of his discomfort, he got a great night's sleep and felt much better. He is swimming away, but mindful to take his calcium/magnesium before and after each swim.

A Simple Horse - Not an Exotic Zebra

This is the perfect example of thinking horses and not zebras in our practices. I do hope you found and encourage you to become a health detective using a whole health approach.
 


References

Ionic Bonding

What Does Magnesium Do for Your Body?

A Whole Person Approach to Health and Healing

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50 Comment(s)

Daisy4RN

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.

Thank you for the great article! I have never heard the Zebra thing before but does remind us to always critical think and look at the big picture. I recently had a shoulder issue and per MD started PT without any imaging/diagnosis. I didn't think this was the right path to go down and thought the MD was just going with the getting older reason. As it turned out it was not the right path as PT didn't help at all and probably made the condition worse.  I should have listened to my own instincts and horse hoofbeats.

Dr Georgianna Donadio, PhD

Specializes in Whole Health and Behavioral Health.

Hi Daisy,
Thank you for your comment and so pleased you liked the article!

I hear you about your PT experience. My leg and hip injury got so much worse on my compensating side and is now much worse than the injury side.
PT can be great but any injury that can worsen with repetitive motion should
probably avoid a PT regiment.

Being a "health detective" is part researcher and part Whole Person Care professional! We teach a course on this approach and people seem to really enjoy examining a condition from a whole different perspective.

Thanks for your comment. Hope your should improves!
Kind regards,
Georgianna

Curious1997, BSN

Specializes in Psych, Medical. Has 13 years experience.

So I don't get this? 

How is the chlorine affecting his Ca and MG? Wouldn't this be the significant finding? Is it being absorbed through his skin and what about him is different physiologically? Is he ingesting the chlorine? 

I would think any of these replacements would be very dangerous and should be carefully monitored by labs. Not looking for zebras, but are there cardiac complications? Renal function? 

This just seems potentially to be a very complicated case. What happens when he sweats? And, just because he felt better from the replacements, does that mean the problem is actually solved? Were there labs before and after to scientifically confirm the findings? 

I think that there's a lot more to this than meets the eye! 

Dr Georgianna Donadio, PhD

Specializes in Whole Health and Behavioral Health.

Hi Curious,
Thanks for your comment. Actually this was a simple case that could have been interpreted as complicated. It is not unusual for people to have chlorine reactions, and yest it is absorbed thru the skin and sometimes it can get into the mouth as well. He has been completely checked out medically and there was no pathology or any red flags that was found. Vitamin and mineral levels fluctuate so much that a blood reading can be frustrating as a primary indication.  His MD did think it might have been a systemic allergy response but didn't discuss the chlorination.

As a nutritionist I was taught that the only real way to measure these values (and they could still vary greatly over the course of a day or hours) was to actually measure the intra-cellular levels which is not something you want to subject someone to except in extreme cases.

The important thing is his symptoms went away with a slight supplements adjustment and no I don't believe his supplementation was dangerous or a concern as he was taking micro-nutrients, which are well utilized, and not mega-vitamins.

The point of the article is that when someone has been medically "vetted" and there is no presenting diagnosis, then rather than looking for an exotic
zebra, it might just be a simple horse hoof beat!

Thanks again for commenting.
Kind regards
Georgianna

Curious1997, BSN

Specializes in Psych, Medical. Has 13 years experience.

How is this being absorbed through the skin and why? The skin is essentially semi permeable but it is also a protective barrier. I imagine that the large surface area would account for the absorption, I just can't figure out the process leading to his symptoms. Legs I can get, but whole body aches? What's the exchange and why isn't his heart involved? Is the chlorine reaching his blood stream, but then what about the kidneys? Is it at a topical level, but how is his muscles involved? And with Mg and Ca, shouldn't his muscles be rapidly contracting? Is there some ionizing process? 

Any chance you can explain the process if you have some time? 

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

9 hours ago, Curious1997 said:

How is this being absorbed through the skin and why? The skin is essentially semi permeable but it is also a protective barrier. I imagine that the large surface area would account for the absorption, I just can't figure out the process leading to his symptoms. Legs I can get, but whole body aches? What's the exchange and why isn't his heart involved? Is the chlorine reaching his blood stream, but then what about the kidneys? Is it at a topical level, but how is his muscles involved? And with Mg and Ca, shouldn't his muscles be rapidly contracting? Is there some ionizing process? 

Any chance you can explain the process if you have some time? 

I’m also a little baffled and need more info. Did you do blood tests to check his calcium and magnesium levels before prescribing it?

klone, MSN, RN

Specializes in Women's Health/OB Leadership. Has 15 years experience.

I disagree - I think the diagnosis is very much a zebra

Dr Georgianna Donadio, PhD

Specializes in Whole Health and Behavioral Health.

Hello All -
Here is some additional information that may clarify your questions
and explain issues with chlorine.

Thanks for your comments!

Chlorine Absorption and Inhalation While Showering, Whole ...

www.superiorwater.com 

Many people believe they are safe from the hazards of chlorine because they don't drink unfiltered tap water. However, people still absorb chlorine when they bathe, shower, or swim in chlorinated pools. ... As with bathing and showering, swimming in chlorinated water is absorbed through the skin.

Those relaxing, hot showers you love to take may be hazardous to your health!  Studies on the health hazards of chlorine added to our public water supplies have been conducted for decades and many of them have caused scientists to conclude that there are many significant health risks.  In some cases scientists have concluded that there are direct links between chlorine intake and serious illnesses in humans and animals.

Many people believe they are safe from the hazards of chlorine because they don’t drink unfiltered tap water.  However,  people  still absorb chlorine when they bathe, shower, or swim in chlorinated pools. In fact, two-thirds of the chlorine taken into the average person’s body comes from taking hot showers.  The reason for this is two-fold.  First, hot water opens the pores and allows water to be absorbed through the skin.  Second, the steam you breathe in while showering can contain up to 50 times the amount of chlorine (and other contaminants) than the water coming out of the tap.

Both the inhaled chlorine and chlorine absorbed through your skin then enters directly into your bloodstream whereas chlorine ingested from drinking tap water is filtered by your liver and kidneys before entering your blood stream.  As with bathing and showering, swimming in chlorinated water is absorbed through the skin. So if you own a pool you should consider alternatives to chlorine such as ozanators and ionizer which only require a small amount of chlorine to be effective.

You can protect yourself and your family from inhalation and skin absorption of chlorine by removing the chlorine before it ever comes out of your shower heads.


From LIVESCIENCE -

An over-chlorinated pool, on the other hand, can cause eye irritation, dry out the hair and skin (by stripping them of natural oils), and sometimes cause color-treated hair to turn shades of green, Duarte told Live Science. Because of this, it's important to have the right levels of chlorine in the pool, she said.

Excess chlorine in the pool can sometimes also cause small amounts of vapor to come out of the water, which "can trigger [a person's] asthma," Duarte said, though she noted that she doesn't think this effect is too common.

"Perhaps it could happen in a freshly chlorinated pool or a super-chlorinated [one]," she said. But as overeager swimmers may recall, pools are typically closed right after pool keepers chlorinate the water so that some of those vapors can diffuse, she said. (In high concentrations, chlorine gas is known to be very poisonous. In World War I, for example, chlorine gas was used as a chemical weapon. Inhaling large amounts of the gas is poisonous and could cause what's called a pulmonary edema, or fluid buildup in the lungs, according to the New York State Department of Health.)

Curious1997, BSN

Specializes in Psych, Medical. Has 13 years experience.

3 hours ago, klone said:

I disagree - I think the diagnosis is very much a zebra

How would you explain the whole body ache without possibility of muscle twitch from the exchange? Why no arrhythmias? The exchange should trigger other symptoms other than achy muscles especially as it was relieved by small dosage supplements. I mean muscles are blood supply nourished, which means all systems involvement. For a large group of muscles to be affected, means serious pathology? Doesn't it? I'm just really intrigued because I just can't figure out the process. 

Dr Georgianna Donadio, PhD

Specializes in Whole Health and Behavioral Health.

Hi Curious,
Body ache is not synonymous with twitching and arrhythmia. When we get the flu we can have all over body ache without these symptoms.

In the 45 years of practicing I have seen numerous cases of reactions to chlorine and many symptoms are well documented. Here is a study from
PUBMED you might find interesting.

Epub 2018 Jan 10.

Influence of chlorinated water on the development of allergic diseases - An overview

Alina Kanikowska 1, Katarzyna Napiórkowska-Baran 2, Małgorzata Graczyk 3, Marcin A Kucharski 4

PMID: 30586974 DOI: 10.26444/aaem/79810

Free article

Abstract

Indoor swimming pools can be used all year round and serve for one of the most popular sport pursued for recreation. The positive effect of swimming arises in particular from the involvement of all the muscles of the body, decreasing the burden on the joints, as well as functional improvement of both the lungs and heart. Chlorine is typically used to disinfect swimming pool water and as a result the changes that take place lead to the formation of by-products, such as monochloramines (NH<sub>2</sub>Cl), dichloramines (NH<sub>2</sub>Cl<sub>2</sub>) I trichloramines (NH<sub>2</sub>Cl<sub>3</sub>), trihalogenometans (THM) or haloacetic acid (HAA). The highest concentration of these substances is just above the water surface and they may cause irritation of skin, eyes and mucosa of the respiratory tract. The toxic effect of high chlorine concentration and its side-products on the respiratory system is known, but the effect of low concentrations of these compounds is still not fully determined [re: myalgia]. Recent studies suggest that development of allergic diseases among swimmers may be increased by epithelial disorders driven by airway barrier dysfunction caused by chlorine irritation. Swimming in chlorinated water may be linked to symptoms of bronchial hyperreactivity, asthma and rhinitis especially in children, elite swimmers and employees of indoor swimming pools. Hypersensivity pneumonitis related to the use of swimming pools may manifest as a swimming pool or sauna user lung, most commonly caused by water polluting pathogens. The article summarizes recent data concerning the influence of chlorinated water on the development of allergic diseases.

Keywords: allergic diseases; allergic rhinitis; asthma; chlorinated water; swimming pool.

Cited by 1 article

Impact of swimming school attendance in 3-year-old children with wheeze and rhinitis at age 5 years: A prospective birth cohort study in Tokyo.

Irahara M, Yamamoto-Hanada K, Yang L, Saito-Abe M, Sato M, Inuzuka Y, Toyokuni K, Nishimura K, Ishikawa F, Miyaji Y, Fukuie T, Narita M, Ohya Y.PLoS One. 2020 Jun 9;15(6):e0234161. doi: 10.1371/journal.pone.0234161. eCollection 2020.PMID: 32516323 

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

19 hours ago, Dr Georgianna Donadio said:



Epub 2018 Jan 10.

Influence of chlorinated water on the development of allergic diseases - An overview

Alina Kanikowska 1, Katarzyna Napiórkowska-Baran 2, Małgorzata Graczyk 3, Marcin A Kucharski 4

PMID: 30586974 DOI: 10.26444/aaem/79810

Free article

Abstract

Indoor swimming pools can be used all year round and serve for one of the most popular sport pursued for recreation. The positive effect of swimming arises in particular from the involvement of all the muscles of the body, decreasing the burden on the joints, as well as functional improvement of both the lungs and heart. Chlorine is typically used to disinfect swimming pool water and as a result the changes that take place lead to the formation of by-products, such as monochloramines (NH<sub>2</sub>Cl), dichloramines (NH<sub>2</sub>Cl<sub>2</sub>) I trichloramines (NH<sub>2</sub>Cl<sub>3</sub>), trihalogenometans (THM) or haloacetic acid (HAA). The highest concentration of these substances is just above the water surface and they may cause irritation of skin, eyes and mucosa of the respiratory tract. The toxic effect of high chlorine concentration and its side-products on the respiratory system is known, but the effect of low concentrations of these compounds is still not fully determined [re: myalgia]. Recent studies suggest that development of allergic diseases among swimmers may be increased by epithelial disorders driven by airway barrier dysfunction caused by chlorine irritation. Swimming in chlorinated water may be linked to symptoms of bronchial hyperreactivity, asthma and rhinitis especially in children, elite swimmers and employees of indoor swimming pools. Hypersensivity pneumonitis related to the use of swimming pools may manifest as a swimming pool or sauna user lung, most commonly caused by water polluting pathogens. The article summarizes recent data concerning the influence of chlorinated water on the development of allergic diseases.

Keywords: allergic diseases; allergic rhinitis; asthma; chlorinated water; swimming pool.

Cited by 1 article

Impact of swimming school attendance in 3-year-old children with wheeze and rhinitis at age 5 years: A prospective birth cohort study in Tokyo.

Irahara M, Yamamoto-Hanada K, Yang L, Saito-Abe M, Sato M, Inuzuka Y, Toyokuni K, Nishimura K, Ishikawa F, Miyaji Y, Fukuie T, Narita M, Ohya Y.PLoS One. 2020 Jun 9;15(6):e0234161. doi: 10.1371/journal.pone.0234161. eCollection 2020.PMID: 32516323 

Yes but that study is about asthma and allergies.... It isn’t related to the case you discussed here. 
And the first link you sent is from a company that sells home water filters.

 

Edited: I took out a comment about this person being a chiropractor, not a nurse. She says below that she is also a nurse. I did still send a report to the moderators related to this pseudoscientific diagnosis. 

Dr Georgianna Donadio, PhD

Specializes in Whole Health and Behavioral Health.

Hello Community RN, BSN - 
Please note there are multiple symptoms found in low levels of chlorine
absorption that are still being researched.

FYI - I have a Masters in Nutrition, a PhD in Health Education and became a nurse in 1968 and practiced for almost 30 years. I was vetted by the administrators when accepted as a writer.

Kind regards,
Georgianna

Curious1997, BSN

Specializes in Psych, Medical. Has 13 years experience.

This is what I think the problem is. I am only 29 and actually very fit. Soccer, tennis, table tennis, squash at least once a week. I am a large guy though and it takes a lot of muscle to move my frame around especially when you are as competitive as I am. Losing is never an option. So pain is my companion. 

He had just started at the gym and as fit as he may have been, it takes a few weeks to stop the pain after sessions. Then he swims after, which can actually be quite physically taxing. I suspect that lactic acid and age are the problems. And replacement of the elements Mg and Ca may have been helpful in an electrolyte sort of way, but I suspect his body adapted or he corrected a technique either in the swimming or lifting. Serum levels could have also built up to the effective pain reduction threshold. 

Just my horse for the race 😂🤔🤗

Dr Georgianna Donadio, PhD

Specializes in Whole Health and Behavioral Health.

Thanks Curious 1997 for your feedback, I appreciate hearing your take on the subject - and congrats on taking care of yourself! 

Just a personal comment from someone old enough to be your grand and may-be great grandmother - losing is part of the life cycle...(you said "losing is never an option") no one likes to do it but you'd be surprised what incredible growth and lessons you can learn from not winning. Ernest Hemingway was known for his quote " The world breaks everyone and afterward many are stronger in the broken places." Be kind to yourself, life is hard - and wonderful - but there are disappointments in all of our lives sooner or later.

Thanks for your comments and feedback,
Kind regards,
Georgianna

 

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

2 hours ago, Dr Georgianna Donadio said:

Hello Community RN, BSN - 
Please note there are multiple symptoms found in low levels of chlorine
absorption that are still being researched.

FYI - I have a Masters in Nutrition, a PhD in Health Education and became a nurse in 1968 and practiced for almost 30 years. I was vetted by the administrators when accepted as a writer.

Kind regards,
Georgianna

Can you link us to some of those studies that are related to the symptoms described in the article?

Daisy4RN

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.

OP, your f/u conversation/info is very informative and interesting! I was recently reading an article about how some believe that allergies are/can be a precursor to autoimmune dx. I have autoimmune dx so it was interesting to see the Inter-connectedness of these too. And, now I am even more curious as I had allergies at a young age and also swam both for sport (at school/rec pools) as well as in private pools, with of course probably more Clorine added to school/public pools. Most HCP (nurses, MD's) don't really study the other factors (Alternative) that can lead to dx or help after one has the dx. I did much research in an attempt to "fix" my own situation as I was getting little relief from my MD (ie western medicine). There is much we (HCP's) don't know/understand! 

Curious1997, BSN

Specializes in Psych, Medical. Has 13 years experience.

36 minutes ago, Dr Georgianna Donadio said:

Thanks Curious 1997 for your feedback, I appreciate hearing your take on the subject - and congrats on taking care of yourself! 

Just a personal comment from someone old enough to be your grand and may-be great grandmother - losing is part of the life cycle...(you said "losing is never an option") no one likes to do it but you'd be surprised what incredible growth and lessons you can learn from not winning. Ernest Hemingway was known for his quote " The world breaks everyone and afterward many are stronger in the broken places." Be kind to yourself, life is hard - and wonderful - but there are disappointments in all of our lives sooner or later.

Thanks for your comments and feedback,
Kind regards,
Georgianna

 

I completely understand. I understand about losing which is why I like winning at sports so much. It's a male thing. In other areas, not really competitive. More of a geek. I have great parents who ingrains the lessons of ups and downs and saving for a rainy day. I really enjoyed that puzzle. Definitely got my gray cells going. 

Keep them coming 👍👍