I recently wrote about penetrating trauma. Today's blog is the first in a series about the much more common, and subtle, blunt trauma. This refers to any trauma from an object striking the body (baseball bat?) or the body inpacting something solid (the ground at the end of a fall). The laws of physics apply to this type of trauma. Energy equals weight times velocity to the second power. Inertia is the tendency of moving objects to continue to move unless acted on by an outside force. This is abundantly evident to those unfortunate and foolish individuals who don't use seatbelts. When the car stops suddenly, the occupants' inertia often throws them out of the vehicle. We in the ER refer to people who ride motorcycles and those who choose to drive in cars without seatbelts as OD (organ donors).
Let's start at the top. The brain is encased in a very solid structure, the skull. The brain is covered by the meninges. They are made up of two thin and one thick membrane that wrap around the brain. There is a small amount of fluid (cerebral spinal fluid, CSF) surrounding the brain and CSF filled cavities(ventricles) within the brain. The arteries and veins that lie under and around the brain are prone to tearing due to direct trauma or deceleration. When bleeding occurs in the rigid skull, the brain will become compressed causing damage to the neurons and herniation of the brain downwards. The foramen magnum is the hole at the base of the skull that is the passage from the brain into the spinal cord. When the pressure from accumulating blood or swelling of the brain tissue builds up, and the brain is forced (herniates) through the foramen magnum, only emergency neurosurgery can save the victim's life.
Deceleration injuries occur whenever the head is moving, and stops abruptly. The head snapping back and forth during a car accident, or when a child is shaken, are prime examples of this type of injury. The impact of the head against a solid object as in a fall or inside a vehicle during a car accident, also causes a sudden decelaration. The outside of the head stops but the brain continues to move until it strikes the inner aspect ot the rigid skull, There are bony ridges in the skull that multiple the damage to the brain. The striking of the brain against the skull and the rebounding and secondary strike on the opposite side is refered to a coup-contracoup injury.
The elderly are particularly prone to intracranial bleeding from even minor blows or deceleration events. The brain atrophies (shrinks) as we age. The space in the cranial vault allows the brain to move more easily. Coup-contracoup injuries and tearing of stretched veins are much more common in older patients. The extra space also allows for bleeding or swelling to not be as apparent, before increased pressure causes damage to the brain or herniation.
Direct impact of the head from objects (sticks and stones...) can fracture or crush the skull. Vessels between the skull and brain can be torn by the fragments of the bony skull. The fracture may force the bones to directly injure the brain. The bones of the face may absorb some of the energy from a direct blow. Fractures involving the facial bones may lead to leaking of CSF and are a potential source of contamination of the brain by bacteria.
A concussion is an injury to the brain that causes dysfunction of the mental processes. A loss of consciousness may or may not occur. Alterations in memory, thought formation, balance or wakefulness appear to some extent. Concussions are graded from first to third degree from minor to severe. The neurological exam is crucial to look for actual structural injury to the brain. An absence of focal (weakness, speech disturbance, visual loss) injury, with a CT that is negative for bleeding, is reassuring that no serious injury to the brain has occured. An MRI may show more subtle injuries to the brain tissue than a CT. Neuropsychological tests are being administered to atheletes to establish a baseline that can be used to assess the impact of a subsequent concussion.
Much has been written and reported in the press, on TV, and the internet about concussions. Subtle abnormalities in tests of coordination and reasoning can be shown even with minor concussions. The key is for recognition of the concussion and the prevention of any further injury to the brain. The higher the degree of concussion, the more time is needed for a complete recovery. Second or third concussions may lead to early onset dementia. Dementia pugilistica (witness Muhammid Ali) is well recognized in boxers but is now known to occur in football players and other athletes who sustain repetitive head injuries.
Appropriate protective head gear and common sense are your best defense. Any loss of consciousness, confusion, memory loss or persistent vomiting after a head injury requires medical evaluation. Let's keep our "wits" about us.
Friday, March 26, 2010
Saturday, March 20, 2010
personality plus; Psi 3
It's 3:00 AM and I am examining a patient for "medical clearance" for a psychiatric evaluation. Within 5 minutes, the patient has really pissed me off. I loathe this patient. This person makes me question my physician's oath. The patient has borderline personality disorder.
Borderline personality disorder (BPD) is defined by our trusty DSM as a pervasive instability in mood, interpersonal relationships, self image and behavior. The borderline is between neurosis (quirky) and psychosis (crazy). Their demeanor can change in an instant as they display anger, depression and anxiety. Crying and sympathetic one minute, cursing and questioning your ancestry the next.
Borderlines are impulsive, aggressive, self-injurous, and often substance abusers. They express feelings that they are unfairly misunderstood and mistreated. There impulsivity leads to splurging, bingeing, and risky behavior including sexual activities.
Borderlines are usually the victims of childhood abuse and neglect. They have an overwhelming fear of abandonment both real and imagined. Their behavior is a way of trying to avoid being abandoned. Suicidal threats and attempts are frequent and accompanied by anger not depression.
It is estimated by the NIMH (National Instutites of Mental Health) that 2% of the adult population has some degree of BPD. Women are more likely to have BPD than men. I treated an attractive young woman in the ER a few years ago. She was crying and relating a history of abuse, depression, drug use and suicidal thoughts. There was a certain degree of "seductive" posturing during the interview and exam. I told her that a mental health worker would come and evaluate her for psychiatric treatment. She mentioned her need for medication to treat her substance abuse problem. I offered appropriate medication but not the specific drug of choice. Her response was instantaneous. The tears were replaced with a snarling, cursing, spitting hellcat. The diagnosis was obvious.
The psychiatric literature is replete with articles about effective treatment with medications and therapy that can allow patients with BPD to lead a near normal life. For those of us who deal with these patients in the ER, a large security force and attention to one own's safety are the priority.
While I am opining about non-psychotic disorders, let's discuss a few additional topics. OCD, GAD, and DID are only occasionally treated in the ER but are often the basis for journalistic articles and TV shows.
OCD stands for obsessive compulsive disorder, think "Monk". This sometimes disabling condition is characterized by recurrent unwanted thoughts (obsessions) with or without repetitive behaviors (compulsions). My coworkers will attest that I am definitely compulsive. I "need" to clean my computer station in the ER before starting to work. The keyboard, phones and mouse are disinfected. Any papers are filed or discarded. My trusted coffee cup and hand sanitizer are to my left, and the phone and a box of tissues to my right. The PA's, nurses and techs are extremely indulgent of my "quirks".
Although the manifestations of OCD are considered humerous by some, to the patient they are painfully serious. Repetitive hand washings, counting, touching and checking can immobilize the patient. The distress of their obsessive thoughts caused severe anxiety. Fortunately medications and behavioral therapy are effective in treating this condition.
DID or dissociative identity disorder was, in the past, refered to as multiple personality disorder ("Sybil"). Two or more separate and distinctive personalities control the individual at different times. These "alters", alternative identities, can number from 2-100, with an average of ten. DID patients experience episodes of amnesia and lost time as one alter changes to another. They have auditory and visual hallucinations, and are often depressed and suicidal. The alters develope as a response to physical and/or sexual abuse in childhood. They are an attempt to cope with the psychological and physical pain of abuse.
GAD is generalized anxiety disorder. Individuals with GAD are constantly worrying or obsessing about small and large concerns. They are always on edge. Restlessness, irritability, lassitude, insomnia, and difficulty concentrating are usually reported. Patients with GAD have physical symptoms from the high levels of stress hormones. Sweats, nausea, diarrhea, shortness of breath and heart palpitations are frequent complaints. Without treatment GAD can lead to a person becoming a shut-in, as one tries to avoid anxiety provoking situations.
PS: ODD or oppositional defiant disorder is a diagnosis given to adolescents and teens. My personal feeling is that this condition is too loosely defined and too easily bestowed. Teenagers are in the process of establishing their identity as distinct persons, independent of their parents. In their efforts to become adults, and due to the late development of the frontal lobes of the brain, teens often do the opposite of what their parents desire. My father had the solution to my ODD, it was a thick and heavy leather strap that he would diligently apply to my posterior when I exhibited oppositional or defiant behavior. I do not recommend and will not tolerate corporal punishment. Clear and consistent standards of behavior and withholding of priviledges is my prefered form of discipline. My opinion is that ODD is more likely to be caused by other underlying psychiatric conditions including bipolar, schizoid personality, and BPD.
PSS: PTSD is fortunately being more often recognized and treated. Soldiers in WW1 were "shell shocked" and in WW2 had "battle fatigue". My father who was in combat for three years in the Pacific theatre during WW2 exhibited all the symptoms of PTSD. He would have frequent nightmares of his war experiences. The only treatment he received was the love and understanding of my mother. Many victims of PTSD are not as lucky. The traumatic event(s) can occur in battle or at home. The intense fear, feelings of helplessness and pain are continually reexperienced. Medication and therapy can help those who suffer from PTSD. Untreated, patients with PTSD will often self-medicate with alcohol and/or drugs. Recent experiments have shown that giving betablockers, a type of medication for high blood pressure, immediately after a traumatic event such as a rape, may blunt or prevent PTSD. The formation of long term memory is impaired by the medication and this seems to be the mechanism for preventing PTSD from developing.
Remember that knowledge is the key to understanding. If you think you or someone you care about has one of these conditions get informed. There are many sources of information available.
Borderline personality disorder (BPD) is defined by our trusty DSM as a pervasive instability in mood, interpersonal relationships, self image and behavior. The borderline is between neurosis (quirky) and psychosis (crazy). Their demeanor can change in an instant as they display anger, depression and anxiety. Crying and sympathetic one minute, cursing and questioning your ancestry the next.
Borderlines are impulsive, aggressive, self-injurous, and often substance abusers. They express feelings that they are unfairly misunderstood and mistreated. There impulsivity leads to splurging, bingeing, and risky behavior including sexual activities.
Borderlines are usually the victims of childhood abuse and neglect. They have an overwhelming fear of abandonment both real and imagined. Their behavior is a way of trying to avoid being abandoned. Suicidal threats and attempts are frequent and accompanied by anger not depression.
It is estimated by the NIMH (National Instutites of Mental Health) that 2% of the adult population has some degree of BPD. Women are more likely to have BPD than men. I treated an attractive young woman in the ER a few years ago. She was crying and relating a history of abuse, depression, drug use and suicidal thoughts. There was a certain degree of "seductive" posturing during the interview and exam. I told her that a mental health worker would come and evaluate her for psychiatric treatment. She mentioned her need for medication to treat her substance abuse problem. I offered appropriate medication but not the specific drug of choice. Her response was instantaneous. The tears were replaced with a snarling, cursing, spitting hellcat. The diagnosis was obvious.
The psychiatric literature is replete with articles about effective treatment with medications and therapy that can allow patients with BPD to lead a near normal life. For those of us who deal with these patients in the ER, a large security force and attention to one own's safety are the priority.
While I am opining about non-psychotic disorders, let's discuss a few additional topics. OCD, GAD, and DID are only occasionally treated in the ER but are often the basis for journalistic articles and TV shows.
OCD stands for obsessive compulsive disorder, think "Monk". This sometimes disabling condition is characterized by recurrent unwanted thoughts (obsessions) with or without repetitive behaviors (compulsions). My coworkers will attest that I am definitely compulsive. I "need" to clean my computer station in the ER before starting to work. The keyboard, phones and mouse are disinfected. Any papers are filed or discarded. My trusted coffee cup and hand sanitizer are to my left, and the phone and a box of tissues to my right. The PA's, nurses and techs are extremely indulgent of my "quirks".
Although the manifestations of OCD are considered humerous by some, to the patient they are painfully serious. Repetitive hand washings, counting, touching and checking can immobilize the patient. The distress of their obsessive thoughts caused severe anxiety. Fortunately medications and behavioral therapy are effective in treating this condition.
DID or dissociative identity disorder was, in the past, refered to as multiple personality disorder ("Sybil"). Two or more separate and distinctive personalities control the individual at different times. These "alters", alternative identities, can number from 2-100, with an average of ten. DID patients experience episodes of amnesia and lost time as one alter changes to another. They have auditory and visual hallucinations, and are often depressed and suicidal. The alters develope as a response to physical and/or sexual abuse in childhood. They are an attempt to cope with the psychological and physical pain of abuse.
GAD is generalized anxiety disorder. Individuals with GAD are constantly worrying or obsessing about small and large concerns. They are always on edge. Restlessness, irritability, lassitude, insomnia, and difficulty concentrating are usually reported. Patients with GAD have physical symptoms from the high levels of stress hormones. Sweats, nausea, diarrhea, shortness of breath and heart palpitations are frequent complaints. Without treatment GAD can lead to a person becoming a shut-in, as one tries to avoid anxiety provoking situations.
PS: ODD or oppositional defiant disorder is a diagnosis given to adolescents and teens. My personal feeling is that this condition is too loosely defined and too easily bestowed. Teenagers are in the process of establishing their identity as distinct persons, independent of their parents. In their efforts to become adults, and due to the late development of the frontal lobes of the brain, teens often do the opposite of what their parents desire. My father had the solution to my ODD, it was a thick and heavy leather strap that he would diligently apply to my posterior when I exhibited oppositional or defiant behavior. I do not recommend and will not tolerate corporal punishment. Clear and consistent standards of behavior and withholding of priviledges is my prefered form of discipline. My opinion is that ODD is more likely to be caused by other underlying psychiatric conditions including bipolar, schizoid personality, and BPD.
PSS: PTSD is fortunately being more often recognized and treated. Soldiers in WW1 were "shell shocked" and in WW2 had "battle fatigue". My father who was in combat for three years in the Pacific theatre during WW2 exhibited all the symptoms of PTSD. He would have frequent nightmares of his war experiences. The only treatment he received was the love and understanding of my mother. Many victims of PTSD are not as lucky. The traumatic event(s) can occur in battle or at home. The intense fear, feelings of helplessness and pain are continually reexperienced. Medication and therapy can help those who suffer from PTSD. Untreated, patients with PTSD will often self-medicate with alcohol and/or drugs. Recent experiments have shown that giving betablockers, a type of medication for high blood pressure, immediately after a traumatic event such as a rape, may blunt or prevent PTSD. The formation of long term memory is impaired by the medication and this seems to be the mechanism for preventing PTSD from developing.
Remember that knowledge is the key to understanding. If you think you or someone you care about has one of these conditions get informed. There are many sources of information available.
Friday, March 12, 2010
Knife and gun club
Every ER doc knows of the Saturday night knife and gun club. Stabbings and shootings are more common on the weekend. The ingestion of alcohol and other intoxicants makes an escalation of disputes to deadly outcomes, much more likely. The frequency of penetrating trauma is higher in inner cities but occurs in every community.
Trauma is roughly divided into blunt and penetrating. A baseball bat and a knife can both cause severe trauma but the mechanism and injuries are relatively specific. Sharp objects such as knives, swords, glass (broken bottle), even knitting needles can easily penetrate the skin and injure deeper structures. Blood vessels, nerves, muscles and tendons are easily damaged in the extremities.
Penetrating a major artery can cause death from blood loss in minutes. The neck and groin are especially vulnerable. Treatment at the scene is critical. An object that is still in place is never removed. The tamponading of the blood vessel by the penetrating object may be all that is preventing exsanguination. Firm pressure and rarely tourniquetting the bleeding vessel is standard care in the field. The ER doc and surgical team can glean helpful information from a description of the weapon and the depth of penetration.
When the neck or trunk are the site of penetration, specific organ injuries must be considered and assessed. The trachea, esophagous, major arteries and veins and crucial nerves course through the neck. These injuries may not be apparent at first but must be suspected and urgently evaluated. The neck is divided into three zones to highlight the most likely injuries from penetrating trauma.
The chest and abdomen contain organs that are easily injured with penetrating weapons. Blood vessels, lungs, solid organs such as the liver and spleen, hollow organs (stomach and intestines), and especially the heart are reachable only inches from the surface of the skin. A knowledge of anatomy and a forensic appreciation of the shape, length and depth of penetration can guide the trauma team.
Pneumothorax is the collapse of the lung. Like a deflated balloon, the lung collapses when the pleura is punctured. A chest tube is inserted into the chest cavity and drains the air and blood in the chest cavity from the injured lung. Bleeding can be severe from the aorta and its branches but also from the intercostal arteries just inside of the ribs. If the heart is penetrated death may be instantaneous. Injuries to the atria give some time for the trauma team to react and perform a thoracotomy. We have all been captivated by the brave ER doc on TV asking for a scalpel and rib spreader. The results on TV were usually successful, much less frequent survival occurs in the real ER.
Abdomenal injuries are often very complex. Bleeding, leakage of bile, gastric and intestinal contents and urine makes for a horrific mess. Infections are frequent and potentially life threatening. Early surgery is determined by imaging studies (CT and/or Ultrasound) and most importantly the patient's vital signs. Tubes are placed in any available opening. Naso-gastric suction and foley catheter (urinary drainage) are mandatory. Large IV's deliver fluids and blood products. Early intubation of the trachea is also practiced.
Energy equals mass times velocity squared. Einstein was not thinking of guns when he wrote E=MC2. Guns come in three basic forms: high velocity (rifles), low velocity (handguns) and pellets (shotguns). They all cause devastating injuries to the human body. 22, 38, and 45 refer to the caliber of a handgun. The caliber is the percentage of an inch that is the diameter of the bullet. A 45 is .45 inches in diameter. The metric measurement is more direct. A 9mm round is 9mm in diameter. A shotgun blast contains many small pellets of steel or lead. The distance from the end of the barrel to the victim helps to determine the extent of the injuries.
The velocity of the bullet is more important than the size. The energy imparted to the victim's body is the square of the velocity. Military and hunting rifles have very high muzzle velocities. These projectiles can easily penentrate the full thickness of the body. The speed of the bullet decreases with distance. This is more important with low velocity handguns than with high velocity rifles.
The bullet's shape and composition is also important to an understanding of the injuries they cause. Soft bullets or hollow point rounds tend to flatten or mushroom when the strike the body. The resulting shock wave is quite large and can tear vessels, and ruptures hollow organ far from the site of entry. Jacketed bullets have a hard outer coat and are more likely to enter and exit the body. There is a large shock wave along the track of the bullet. This often is visible as a small entry wound and a much larger exit wound.
Small bullets, or pellets from an airgun or shotgun can penetrate into a blood vessel and travel quite far from the entry site. When the pellet finally lodges in a small vessel, such as in the brain, the result would be a stroke. If the final resting place for the wandering pellet is in a limb, the trauma team will note a sudden loss of blood flow to that limb.
As a resident, I treated a gentleman for a boil on his buttocks. When I opened the abscess to promote drainage, I found a 22 caliber copper jacketed bullet. On further questioning, my patient related a story of a poker game gone bad some 7 years prior to our encounter. He felt some thing "bite my ass" as he exited the game after being accused of cheating. Small caliber + low velocity= bullet lodged in the buttocks.
I do not own a gun. I am not a hunter. I have fired handguns, rifles and shotguns. ER docs who see the devastation caused by guns are divided in their opinions concerning gun ownership. A recent episode in Massachusetts is instructive and troubling. An ER doc from Connecticut who is a gun owner, brought his 8 year old son to a gun show. His son was given a 9mm automatic weapon that can fire up to 200 rounds per minute. A 15 year old "instructor" was supervising the 8 year old. As the boy fired the weapon, the recoil caused the gun to elevate and the barrel to go towards the boy. He was killed with the very weapon he was firing. The NRA bumper sticker reads: "Guns don't kill people, people kill people". Discuss.
Trauma is roughly divided into blunt and penetrating. A baseball bat and a knife can both cause severe trauma but the mechanism and injuries are relatively specific. Sharp objects such as knives, swords, glass (broken bottle), even knitting needles can easily penetrate the skin and injure deeper structures. Blood vessels, nerves, muscles and tendons are easily damaged in the extremities.
Penetrating a major artery can cause death from blood loss in minutes. The neck and groin are especially vulnerable. Treatment at the scene is critical. An object that is still in place is never removed. The tamponading of the blood vessel by the penetrating object may be all that is preventing exsanguination. Firm pressure and rarely tourniquetting the bleeding vessel is standard care in the field. The ER doc and surgical team can glean helpful information from a description of the weapon and the depth of penetration.
When the neck or trunk are the site of penetration, specific organ injuries must be considered and assessed. The trachea, esophagous, major arteries and veins and crucial nerves course through the neck. These injuries may not be apparent at first but must be suspected and urgently evaluated. The neck is divided into three zones to highlight the most likely injuries from penetrating trauma.
The chest and abdomen contain organs that are easily injured with penetrating weapons. Blood vessels, lungs, solid organs such as the liver and spleen, hollow organs (stomach and intestines), and especially the heart are reachable only inches from the surface of the skin. A knowledge of anatomy and a forensic appreciation of the shape, length and depth of penetration can guide the trauma team.
Pneumothorax is the collapse of the lung. Like a deflated balloon, the lung collapses when the pleura is punctured. A chest tube is inserted into the chest cavity and drains the air and blood in the chest cavity from the injured lung. Bleeding can be severe from the aorta and its branches but also from the intercostal arteries just inside of the ribs. If the heart is penetrated death may be instantaneous. Injuries to the atria give some time for the trauma team to react and perform a thoracotomy. We have all been captivated by the brave ER doc on TV asking for a scalpel and rib spreader. The results on TV were usually successful, much less frequent survival occurs in the real ER.
Abdomenal injuries are often very complex. Bleeding, leakage of bile, gastric and intestinal contents and urine makes for a horrific mess. Infections are frequent and potentially life threatening. Early surgery is determined by imaging studies (CT and/or Ultrasound) and most importantly the patient's vital signs. Tubes are placed in any available opening. Naso-gastric suction and foley catheter (urinary drainage) are mandatory. Large IV's deliver fluids and blood products. Early intubation of the trachea is also practiced.
Energy equals mass times velocity squared. Einstein was not thinking of guns when he wrote E=MC2. Guns come in three basic forms: high velocity (rifles), low velocity (handguns) and pellets (shotguns). They all cause devastating injuries to the human body. 22, 38, and 45 refer to the caliber of a handgun. The caliber is the percentage of an inch that is the diameter of the bullet. A 45 is .45 inches in diameter. The metric measurement is more direct. A 9mm round is 9mm in diameter. A shotgun blast contains many small pellets of steel or lead. The distance from the end of the barrel to the victim helps to determine the extent of the injuries.
The velocity of the bullet is more important than the size. The energy imparted to the victim's body is the square of the velocity. Military and hunting rifles have very high muzzle velocities. These projectiles can easily penentrate the full thickness of the body. The speed of the bullet decreases with distance. This is more important with low velocity handguns than with high velocity rifles.
The bullet's shape and composition is also important to an understanding of the injuries they cause. Soft bullets or hollow point rounds tend to flatten or mushroom when the strike the body. The resulting shock wave is quite large and can tear vessels, and ruptures hollow organ far from the site of entry. Jacketed bullets have a hard outer coat and are more likely to enter and exit the body. There is a large shock wave along the track of the bullet. This often is visible as a small entry wound and a much larger exit wound.
Small bullets, or pellets from an airgun or shotgun can penetrate into a blood vessel and travel quite far from the entry site. When the pellet finally lodges in a small vessel, such as in the brain, the result would be a stroke. If the final resting place for the wandering pellet is in a limb, the trauma team will note a sudden loss of blood flow to that limb.
As a resident, I treated a gentleman for a boil on his buttocks. When I opened the abscess to promote drainage, I found a 22 caliber copper jacketed bullet. On further questioning, my patient related a story of a poker game gone bad some 7 years prior to our encounter. He felt some thing "bite my ass" as he exited the game after being accused of cheating. Small caliber + low velocity= bullet lodged in the buttocks.
I do not own a gun. I am not a hunter. I have fired handguns, rifles and shotguns. ER docs who see the devastation caused by guns are divided in their opinions concerning gun ownership. A recent episode in Massachusetts is instructive and troubling. An ER doc from Connecticut who is a gun owner, brought his 8 year old son to a gun show. His son was given a 9mm automatic weapon that can fire up to 200 rounds per minute. A 15 year old "instructor" was supervising the 8 year old. As the boy fired the weapon, the recoil caused the gun to elevate and the barrel to go towards the boy. He was killed with the very weapon he was firing. The NRA bumper sticker reads: "Guns don't kill people, people kill people". Discuss.
Friday, March 5, 2010
He ain't heavy, he's my brother
Plump, full figured, overweight, obese, fat... Americans are overweight and the problem is getting worse. As a child in the 50's, I remember that there being very few heavy kids. They were called "husky". We rarely ate food not prepared by our mothers. We played outside after school and even had outdoor recess in elementary school. There were few channels on the black and white TV. In the 21st century children have lots of electronic distractions. Parents are so protective, that children are only allowed outdoors under adult supervision. Fast food and abundant junk foods contain more calories, sugar, and fat. The statistical evidence is confirmed by personal observation, patients of all ages are getting larger.
Type 2 diabetes is now a pediatric disease. Bariatric surgery is a growth industry. Equipment has to be supersized. Wheelchairs wider than my couch, scanners that have to have augmented gantry motors. Even our 450 lb scanner is sometimes not adequate. Simple IV access can become a time consuming and sometimes impossible process. CPR is ineffective as chest compresses are insufficient to give useful circulation. Our colleagues in veterinary practice have made their large animal CT and MRI machines available for our largest patients.
Obseity has deleterious effects on many body systems. The joints and bones cannot enlarge to support the extra bulk. Arthritis, compression fractures and ruptured ligaments and tendons are more common. I treated a 400+ lb man who ruptured his patella tendon in a simple fall. My PA tried to find a long leg immobilizer to stabilize his knee. The patient was unable to do non-weight bearing because of his size and even the largest knee immobilizer was to small to fit around his leg.
The early onset arthritis makes it difficult for the motivated obese patient to exercise effectively. Morbidly obese patients have restrictive lung disease from their own body weight crushing the chest cavity. Obesity is closely linked to sleep apnea.
Diabetes and hypertension are markedly increased with increased body weight. The risk of heart disease and stroke is similarly elevated. Entubation, IV access, anesthesia and skin care are all more difficult and may lead to more complications.
The ER, as the first line of medical care for many people, is attempting to cope with the needs of our ever "expanding" patient population. Ultrasound for assisting in IV insertion and lumbar puncture is available and helpful. Fiberoptic entubation can be life saving. Mechanical chest compressors are more effective than all but the strongest human CPR providers. Having a second, heavyduty CT scanner extends our ability to evaluate larger patients. Most of our wheelchairs are "double wides".
I have mentioned 2 of the possible causes of weight increase in the US; increased intake of high caloric foods and decreased physical activity. Other factors have been tentatively identified including increased use of hormones in farm animals and contaminates in our foods that may imcrease weight gain. The solution to weight loss is simple to state but extremely hard to accomplish. One needs to take in less calories than they expend, eat less and exercise more.
After many attempts at dieting with weight loss and rebound weight gain, a person can get desperate. The solution is bariatric surgery; at least according to the American College of Surgeons. There are three main types of weight loss surgery. The earliest surgeries involved "stomach stapling". A large portion of the stomach was stapled closed. Only a small tract of the upper stomach remained. Overeating would lead to vomiting. Weight loss was dramatic and rapid. The stomach remnant could only hold 1-3 ounces of food. Complications could be dangerous as infections and bleeding in an obese and often diabetic patient made management more difficult.
Gastric bypass was the second major variation of baritric surgery. The
"roux-en-y" gastric bypass is more complicated than a stomach stapling. A loop of intestine is closed at one end and the other end is attached to the closed off area of the stomach. Again, weight loss is impressive. There are also significant complications. Bleeding and infections are the most serious. Gall bladder disease, chronic diarrhea, and obstruction are more frequent but less deadly.
The newest and least invasive technique is the gastric or "lap" band. An adjustable ring is placed at the upper part of the stomach. This leaves a very small volume for food. Too tight a ring leads to vomiting, and too loose a ring can lead to inadequate weight loss. The ring can slip, and can cause erosion throught the wall of the stomach.
When a bariatric surgery patient has problems and calls the surgeon's office they are advised to go to the ER. If your hospital has surgeons who perform bariatric procedures, their patients will end up being your patients. A recent case is illustrative. The local bariatric surgeon was called by an ER doc from out of town. The surgeon's patient had a complication of the roux-en-y gastric bypass. This was confirmed by CT. When called by the ER doc at the out of area hospital, the surgeon instructed the ER doc to send the patient to me. The surgeon got to sleep and skillfully repaired the problem the next morning. I was only too happy to act as the hired help for the surgeon. The patient, being my first priority, was given pain medication and kept stable until the surgeon arrived the next morning.
I would be remiss if I didn't address the work related injuries that the obese patient can cause to the ER staff. Having to move, tranfer and turn hundreds of pounds of patient is not good for the backs of the nurses, aides, PA's or docs.
No easy solutions is available for the epidemic of obesity in the US. Taxes on junk food, listing BMI (body mass index, a measure of obesity) on childrens report cards, and public campaigns have all been proposed or instituted. I will admit that my BMI is 21. I am thin. I exercise daily and limit my caloric intake. I have maintained the same body weight my entire adult life. Much credit goes to good genes. My parents are both of normal body weight for their height.
A few simple suggestions: shut off the TV, computer, and video gamer. Put on you MP3 player and take a walk. Remember that eating fried anything is not a good idea for someone trying to lose weight. French fries are not a vegetable. When asked, "would you like to supersize that", say no thank you. Even modest weight loss in the severely obese can improve their overall health.
Type 2 diabetes is now a pediatric disease. Bariatric surgery is a growth industry. Equipment has to be supersized. Wheelchairs wider than my couch, scanners that have to have augmented gantry motors. Even our 450 lb scanner is sometimes not adequate. Simple IV access can become a time consuming and sometimes impossible process. CPR is ineffective as chest compresses are insufficient to give useful circulation. Our colleagues in veterinary practice have made their large animal CT and MRI machines available for our largest patients.
Obseity has deleterious effects on many body systems. The joints and bones cannot enlarge to support the extra bulk. Arthritis, compression fractures and ruptured ligaments and tendons are more common. I treated a 400+ lb man who ruptured his patella tendon in a simple fall. My PA tried to find a long leg immobilizer to stabilize his knee. The patient was unable to do non-weight bearing because of his size and even the largest knee immobilizer was to small to fit around his leg.
The early onset arthritis makes it difficult for the motivated obese patient to exercise effectively. Morbidly obese patients have restrictive lung disease from their own body weight crushing the chest cavity. Obesity is closely linked to sleep apnea.
Diabetes and hypertension are markedly increased with increased body weight. The risk of heart disease and stroke is similarly elevated. Entubation, IV access, anesthesia and skin care are all more difficult and may lead to more complications.
The ER, as the first line of medical care for many people, is attempting to cope with the needs of our ever "expanding" patient population. Ultrasound for assisting in IV insertion and lumbar puncture is available and helpful. Fiberoptic entubation can be life saving. Mechanical chest compressors are more effective than all but the strongest human CPR providers. Having a second, heavyduty CT scanner extends our ability to evaluate larger patients. Most of our wheelchairs are "double wides".
I have mentioned 2 of the possible causes of weight increase in the US; increased intake of high caloric foods and decreased physical activity. Other factors have been tentatively identified including increased use of hormones in farm animals and contaminates in our foods that may imcrease weight gain. The solution to weight loss is simple to state but extremely hard to accomplish. One needs to take in less calories than they expend, eat less and exercise more.
After many attempts at dieting with weight loss and rebound weight gain, a person can get desperate. The solution is bariatric surgery; at least according to the American College of Surgeons. There are three main types of weight loss surgery. The earliest surgeries involved "stomach stapling". A large portion of the stomach was stapled closed. Only a small tract of the upper stomach remained. Overeating would lead to vomiting. Weight loss was dramatic and rapid. The stomach remnant could only hold 1-3 ounces of food. Complications could be dangerous as infections and bleeding in an obese and often diabetic patient made management more difficult.
Gastric bypass was the second major variation of baritric surgery. The
"roux-en-y" gastric bypass is more complicated than a stomach stapling. A loop of intestine is closed at one end and the other end is attached to the closed off area of the stomach. Again, weight loss is impressive. There are also significant complications. Bleeding and infections are the most serious. Gall bladder disease, chronic diarrhea, and obstruction are more frequent but less deadly.
The newest and least invasive technique is the gastric or "lap" band. An adjustable ring is placed at the upper part of the stomach. This leaves a very small volume for food. Too tight a ring leads to vomiting, and too loose a ring can lead to inadequate weight loss. The ring can slip, and can cause erosion throught the wall of the stomach.
When a bariatric surgery patient has problems and calls the surgeon's office they are advised to go to the ER. If your hospital has surgeons who perform bariatric procedures, their patients will end up being your patients. A recent case is illustrative. The local bariatric surgeon was called by an ER doc from out of town. The surgeon's patient had a complication of the roux-en-y gastric bypass. This was confirmed by CT. When called by the ER doc at the out of area hospital, the surgeon instructed the ER doc to send the patient to me. The surgeon got to sleep and skillfully repaired the problem the next morning. I was only too happy to act as the hired help for the surgeon. The patient, being my first priority, was given pain medication and kept stable until the surgeon arrived the next morning.
I would be remiss if I didn't address the work related injuries that the obese patient can cause to the ER staff. Having to move, tranfer and turn hundreds of pounds of patient is not good for the backs of the nurses, aides, PA's or docs.
No easy solutions is available for the epidemic of obesity in the US. Taxes on junk food, listing BMI (body mass index, a measure of obesity) on childrens report cards, and public campaigns have all been proposed or instituted. I will admit that my BMI is 21. I am thin. I exercise daily and limit my caloric intake. I have maintained the same body weight my entire adult life. Much credit goes to good genes. My parents are both of normal body weight for their height.
A few simple suggestions: shut off the TV, computer, and video gamer. Put on you MP3 player and take a walk. Remember that eating fried anything is not a good idea for someone trying to lose weight. French fries are not a vegetable. When asked, "would you like to supersize that", say no thank you. Even modest weight loss in the severely obese can improve their overall health.
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