TGIF. Yes another weekend is upon us. Golf, tennis, hiking, running, biking, yard work. Money in the bank for the ER. Sprains, strains, stress fractures, sunburns and rashes all end up in the ER. Quick turn around and easy income, I love the weekend.
The added bonus is that spring has sprung. All those coach potatoes that have been rooted in front of the tube for the past 4 months are now coming out of hibernation. Muscles, tendons, ligaments, and joints atrophy without regular exercise. Swinging a driver after a winter of inactivity is sure to put a strain on your back and shoulders. Hitting the road for that first run since November may lead to tendonitis, arthralgias even stress fractures.
The recent Boston Marathon was a bonanza for local ER's. I saw the daughter of a dear friend who had run her first marathon and came in with severe foot pain the next day. Plantar fasciitis vs stress fracture, only the x-ray tech knows for sure. Stress fractures are subtle injuries to the bones from repetitive or sudden overuse. An initial x-ray may be normal. If the history is consistent, treatment is rest and limiting use of the injured part. A repeat x-ray in 2-3 weeks will reveal the fracture. Bone scans and MRI will show the injury earlier than plain x-ray.
Athletes who play their games on the weekend are ill prepared for the stresses on their bodies. Without proper training and conditioning the risk of injury is high. Muscle strains or tears are common. Ligamentous injuries to the ankles and knees, sprains, occur frequently. Ruptured tendons especially the Achilles tendon are severe injuries for our intrepid jocks. The calf muscles attach to the heel by the Achilles tendon. Jumping, running, pushing off can cause the unconditioned tendon to tear. The patella tendon in the front of the leg is also prone to rupture in the weekend athlete. The tendons at the elbow are often injured by baseball, softball, and tennis enthusiasts. Tennis elbow and pitcher's elbow are example of tendonitis from excessive strain on tendon attachments.
The shoulder is often the site of sports and recreational injuries. The mobility of the shoulder leaves it vulnerable to damage. The head of the humerus (upper arm bone) is held in the glenoid fossa by a ring of tissue, the rotator cuff. Falls, throwing, and wrestling can easily tear this cuff. The shoulder, like all large joints has bursas. These are fluid filled sacs that act to lubricate and promote the movements of ligaments and tendons around the joint. Overuse and aging lead to inflammation of these sacs, bursitis. Bursitis may be acute or chronic. Chronic inflamation leads to calcium being depositing in the bursa. Sharp, painful calcium spikes in a bursa is a call to get to the ER.
The knee has a complex anatomy that performed well for the running life style of our ancestors. Twisting, planting the foot and cutting, and getting hit with the foot encased in cleats is not good for one's knees. There are four main ligaments of the knee. The anterior and posterior cruciate ligaments are in the middle of the joint. They give stability to movements of the knee front to back. The lateral and medial collateral ligaments stabilize the knee to stress from the sides. The menisci are the two horseshoe shaped cartilages that cushion the movements of the femur and tibia. Fixing the foot and twisting may tear these structures.
The ankle is prone to sprains. The ligaments of this joint are easily stretched or torn by the rocking and rolling movements of football (pigskin-type, or soccer), basketball and baseball. Sprains are graded first to third degree. The higher the degree, the greater the damage to the ligaments. Third degree sprains may require surgery to reestablish the integrity of the joint. RICE: rest, ice, compression and elevation are the best treatment for mild sprains.
The world's oldest ER doc has had his share of orthopedic problems. I was a dedicated runner from an early age. Overuse injuries have made me an elliptical trainer devotee. Cross training with a rowing machine and free weights keep me fit and painfree. My advice to the athletes out there is to be active every day. Walk, run, bike, and lift regularly and smartly. Sitting at a desk all week and then playing sports on the weekend will lead to injury. Use proper equipment and foot wear. Stop when you feel pain. Warm up gradually. Stretch after you have warmed your muscles and before strenuous activities.
A last word about cycling, for men only. Sitting on a bicycle seat for those long rides can lead to injury to the blood vessels and nerves involved with an erection. ED, erectile dysfunction is rampant with cyclists. Wear padded shorts and use a padded or split-type seat. Frequently get off your seat, and up on your pedals as you ride. If you still get ED, there is always vitamin V.
Friday, April 30, 2010
Friday, April 23, 2010
Man's best friend?
Cats and dogs have lived with homo sapiens for thousands of years. Dogs were domesticated from wild canid species, most likely wolves before recorded history. Cats are well represented in the hieroglyphics of the ancient Egyptians and their remains have been found in even more ancient cultures by archaeologists. We seem to have an innate need to be with animals. Studies have shown that merely petting a dog or cat can lower blood pressure and reduce the levels of stress hormones. Reptiles, birds, fish and the occasional hedgehog or pot bellied pig are all part of the household menagerie of our society.
The ER take on household animals is a reality show called "When Pets Go Bad". 4.5 million people in the US will be bitten by a dog in the average year. 75% of these bites are from the family pet or a friend's pet. Small children and adult males are the most likely victims. Dogs attack because of threats to their food, water, territory or out of fear or insecurity. Any dog may bite, but larger more aggressive breeds bite more often, and the resulting injuries are more severe. The size and shape of dog's teeth and the strength of their jaw muscles produce both crushing and tearing trauma.
Dog bites should be copiously irrigated with clean water or saline solution. Tetanus prophylaxis may be given. The location and severity of the bite will determine if primary closure is appropriate. Dog bites are less likely to cause bacterial infections than human or other primate species' bites.
Dogs may be a source for parasitic infections from hook and pin worms. Good hygiene habits, having your dog wormed and cleaning up your dogs droppings will help to reduce this health risk
Like their wolf ancestors, dogs are pack animals. In the home, it is important that the owner be the dominant member of the pack. Proper training, socializing, neutering and spaying are crucial. Controlling the dog with fencing and a leash will prevent most dog bites. Dogs have been bred for many functions from herding to tracking to hunting to protection. I admit that I own a male dog of one of the breeds considered dangerous. He is very much beta to my alpha status. It has been said that there are no bad dogs, only bad owners.
Being allergic to cats, I am not a cat person. Cats make wonderful pets but they carry specific risks to their owners. A cat bite is a puncture wound. The bacteria in their mouths are driven deeply into the tissue. Vessels and tendons may be injured. Cat scratch fever is a bacterial infection transmitted by scratches or bites. The symptoms include fever, headaches, swollen regional lymph nodes and a nodule at the site of the injury. Cats are a known source of toxoplasma. This parasite can cause severe birth defects if a pregnant woman is exposed. Women who are pregnant or may be pregnant should not handle litter boxes or soil where cats defecate.
Rabies is a viral infection that is transmitted from an infected animal by bite or scratch. Even contact with an infected animal's fur may be enough to pass on the infection. In the US, canine rabies is extremely rare. Unvaccinated cats, especially feral cats are a known reservoir. Bats, foxes, raccoons, coyotes, skunks and even cattle have been known to harbor the virus. To confirm the presence of rabies requires that animal be quarantined or more commonly euthanized and the brain examined. If the source animal is not available, the patient must undergo a painful but uniformly successful course of treatment.
Rabies immune globulin is given as soon as possible after the exposure to provide passive immunity to the virus. A series of rabies vaccinations is also started to induce active immunity to the disease. The treatment cost several thousand dollars. Untreated rabies was once thought to be fatal in all cases. A treatment regimen, the Milwaukee Protocol has been developed and has been successful in preventing death in some cases. The patient is placed in a medically induced coma and antiviral medications are given. Vaccinating cats and dogs and using common sense in dealing with any feral animal is far better than the alternatives.
Exotic pets are becoming ever more popular. Reptiles, birds, fish, and mammals (ferrets, hedgehogs, monkeys) are all kept as pets. Besides the inevitables injuries from tooth, claw or beak, many of these pets harbor specific diseases that effect and infect their owners. Reptiles and birds often carry salmonella, a nasty gastrointestinal bacterial infection. Parrots and their relatives may be sources of C psittaci, the bacteria that cause psittacosis. The pneumonia from this organism is especially dangerous to those with diminished immunity or pre-existing lung disease. Pigeon droppings often contain cryptococcal spores. In immunosupressed people, cryptococcoal infections of the central nervous system are very dangerous. Allergic lung problems can also be caused by pigeon droppings in some owners. Monkeys often carry hepatitis B and monkey bites have a very high risk of bacterial infection.
Why do we share our lives with our pets? When I arrive home tired and cranky (my usual condition), even when I reek from sweat, my "puppy" greets me with wagging tail and lapping tongue. My saintly wife makes me bath before giving me a kiss.
The ER take on household animals is a reality show called "When Pets Go Bad". 4.5 million people in the US will be bitten by a dog in the average year. 75% of these bites are from the family pet or a friend's pet. Small children and adult males are the most likely victims. Dogs attack because of threats to their food, water, territory or out of fear or insecurity. Any dog may bite, but larger more aggressive breeds bite more often, and the resulting injuries are more severe. The size and shape of dog's teeth and the strength of their jaw muscles produce both crushing and tearing trauma.
Dog bites should be copiously irrigated with clean water or saline solution. Tetanus prophylaxis may be given. The location and severity of the bite will determine if primary closure is appropriate. Dog bites are less likely to cause bacterial infections than human or other primate species' bites.
Dogs may be a source for parasitic infections from hook and pin worms. Good hygiene habits, having your dog wormed and cleaning up your dogs droppings will help to reduce this health risk
Like their wolf ancestors, dogs are pack animals. In the home, it is important that the owner be the dominant member of the pack. Proper training, socializing, neutering and spaying are crucial. Controlling the dog with fencing and a leash will prevent most dog bites. Dogs have been bred for many functions from herding to tracking to hunting to protection. I admit that I own a male dog of one of the breeds considered dangerous. He is very much beta to my alpha status. It has been said that there are no bad dogs, only bad owners.
Being allergic to cats, I am not a cat person. Cats make wonderful pets but they carry specific risks to their owners. A cat bite is a puncture wound. The bacteria in their mouths are driven deeply into the tissue. Vessels and tendons may be injured. Cat scratch fever is a bacterial infection transmitted by scratches or bites. The symptoms include fever, headaches, swollen regional lymph nodes and a nodule at the site of the injury. Cats are a known source of toxoplasma. This parasite can cause severe birth defects if a pregnant woman is exposed. Women who are pregnant or may be pregnant should not handle litter boxes or soil where cats defecate.
Rabies is a viral infection that is transmitted from an infected animal by bite or scratch. Even contact with an infected animal's fur may be enough to pass on the infection. In the US, canine rabies is extremely rare. Unvaccinated cats, especially feral cats are a known reservoir. Bats, foxes, raccoons, coyotes, skunks and even cattle have been known to harbor the virus. To confirm the presence of rabies requires that animal be quarantined or more commonly euthanized and the brain examined. If the source animal is not available, the patient must undergo a painful but uniformly successful course of treatment.
Rabies immune globulin is given as soon as possible after the exposure to provide passive immunity to the virus. A series of rabies vaccinations is also started to induce active immunity to the disease. The treatment cost several thousand dollars. Untreated rabies was once thought to be fatal in all cases. A treatment regimen, the Milwaukee Protocol has been developed and has been successful in preventing death in some cases. The patient is placed in a medically induced coma and antiviral medications are given. Vaccinating cats and dogs and using common sense in dealing with any feral animal is far better than the alternatives.
Exotic pets are becoming ever more popular. Reptiles, birds, fish, and mammals (ferrets, hedgehogs, monkeys) are all kept as pets. Besides the inevitables injuries from tooth, claw or beak, many of these pets harbor specific diseases that effect and infect their owners. Reptiles and birds often carry salmonella, a nasty gastrointestinal bacterial infection. Parrots and their relatives may be sources of C psittaci, the bacteria that cause psittacosis. The pneumonia from this organism is especially dangerous to those with diminished immunity or pre-existing lung disease. Pigeon droppings often contain cryptococcal spores. In immunosupressed people, cryptococcoal infections of the central nervous system are very dangerous. Allergic lung problems can also be caused by pigeon droppings in some owners. Monkeys often carry hepatitis B and monkey bites have a very high risk of bacterial infection.
Why do we share our lives with our pets? When I arrive home tired and cranky (my usual condition), even when I reek from sweat, my "puppy" greets me with wagging tail and lapping tongue. My saintly wife makes me bath before giving me a kiss.
Friday, April 16, 2010
Musings
A grey and cold spring day sets the B.O.N.E.R. doc's mind drifting into some dusty corners. I was recently chastised for my infliction of boorish behavior on the ER nursing staff. As the world's oldest ER doc, I have been witness and sometimes the victim of the rapid changes in the delivery of health care.
Back in the dark ages, doctors were demi-gods. We ran the hospitals. Nurses would take orders and say, yes Doctor. The death of a dear and treasured friend reminded me of the demise of this paradigm. When I arrived at my current hospital, I was residency trained and board certified in Emergency Medicine. This made me a rare bird. No other hospital in the area had a "real" emergency medicine specialist. I had been at a major teaching hospital prior to my debut at the Generic Hospital.
Three senior nurse supervisors gave me my first lesson in how the ER was changing. They welcomed me and offered me their friendship. Titles and last names were strictly followed. I was Dr X and they were Mrs. Y. There was no doubt who had the real power; it wasn't me. Forging ahead, I worked with many wonderful nurses. As I educated them in the latest trends in EM, they schooled me in the politics and policies of ER management.
Health care management continued to evolve. I never had a problem with maintaining my knowledge of the new equipment, medications and diseases that an ER doc faced. The relation between doctors and nurses and doctors and administrators was much more difficult for me to handle. My mentor and boss was and is my shining example of how a physician should adapt to this new partnership in health care.
Today I often find myself conflicted. I am still a good ER doc. Thirty years of experience has made me effective and efficient. Thirty years of the stress, sleep deprivation and ingrained behavior have made me a cranky and often difficult person to work with. Press-Ganey patient surveys and empowered nurses make me feel like time has passed me by.
Hospital management rightly recognizes that medicine is a customer oriented business. Patients, their families and hospital employees must be given reasons to choose Hospital Z vs Hospital W. A work environment that is supportive and cooperative is mandatory. The patients and their family expect excellent treatment along with a customer first approach.
What is a dinosaur to do? Adapt or move on. I took a course in workplace conflict and communication. My director and friend has the difficult job of trying to keep me from career suicide. Why continue? I love being an ER doc. I get to help people and occasionally save a life.
This past week, two patients reminded me of why I persevere.
An elderly woman arrived from the nursing home in respiratory distress. Her son and grandchildren were at the bedside. The patient had a Do Not Resuscitate directive. She was in end-stage congestive heart failure. Her lungs filled with edema, she struggled to breath. Her son and I talked about options. I offered to give her small doses of morphine. He and I agreed that the humane course was to give her the morphine understanding that it would hasten her inevitable death. She died a few hours later but was much less distressed during those hours.
On another recent night, I saw a friend come staggering into the ER. Pale, sweaty, and clutching his chest, the diagnosis was obvious. The intervention cardiac team was activated and my friend had a successful angioplasty. My friend looked at me and said "I knew you would be on". His confidence in me and his appreciation of my efforts are why I will continue to be the "world's oldest ER doc".
Back in the dark ages, doctors were demi-gods. We ran the hospitals. Nurses would take orders and say, yes Doctor. The death of a dear and treasured friend reminded me of the demise of this paradigm. When I arrived at my current hospital, I was residency trained and board certified in Emergency Medicine. This made me a rare bird. No other hospital in the area had a "real" emergency medicine specialist. I had been at a major teaching hospital prior to my debut at the Generic Hospital.
Three senior nurse supervisors gave me my first lesson in how the ER was changing. They welcomed me and offered me their friendship. Titles and last names were strictly followed. I was Dr X and they were Mrs. Y. There was no doubt who had the real power; it wasn't me. Forging ahead, I worked with many wonderful nurses. As I educated them in the latest trends in EM, they schooled me in the politics and policies of ER management.
Health care management continued to evolve. I never had a problem with maintaining my knowledge of the new equipment, medications and diseases that an ER doc faced. The relation between doctors and nurses and doctors and administrators was much more difficult for me to handle. My mentor and boss was and is my shining example of how a physician should adapt to this new partnership in health care.
Today I often find myself conflicted. I am still a good ER doc. Thirty years of experience has made me effective and efficient. Thirty years of the stress, sleep deprivation and ingrained behavior have made me a cranky and often difficult person to work with. Press-Ganey patient surveys and empowered nurses make me feel like time has passed me by.
Hospital management rightly recognizes that medicine is a customer oriented business. Patients, their families and hospital employees must be given reasons to choose Hospital Z vs Hospital W. A work environment that is supportive and cooperative is mandatory. The patients and their family expect excellent treatment along with a customer first approach.
What is a dinosaur to do? Adapt or move on. I took a course in workplace conflict and communication. My director and friend has the difficult job of trying to keep me from career suicide. Why continue? I love being an ER doc. I get to help people and occasionally save a life.
This past week, two patients reminded me of why I persevere.
An elderly woman arrived from the nursing home in respiratory distress. Her son and grandchildren were at the bedside. The patient had a Do Not Resuscitate directive. She was in end-stage congestive heart failure. Her lungs filled with edema, she struggled to breath. Her son and I talked about options. I offered to give her small doses of morphine. He and I agreed that the humane course was to give her the morphine understanding that it would hasten her inevitable death. She died a few hours later but was much less distressed during those hours.
On another recent night, I saw a friend come staggering into the ER. Pale, sweaty, and clutching his chest, the diagnosis was obvious. The intervention cardiac team was activated and my friend had a successful angioplasty. My friend looked at me and said "I knew you would be on". His confidence in me and his appreciation of my efforts are why I will continue to be the "world's oldest ER doc".
Sunday, April 11, 2010
Stingers
There are three members of the arthropods that injure humans by the injection of venom. They are spiders, scorpions and the social insects (hymenoptera). Although the venom of these creatures is by itself only rarely fatal, an allergic reaction to the bite may be lethal.
Of the hundreds of species of scorpions, only 25 are poisonous to humans. In the US scorpion stings are predominately found in the Southwest. Some "hobbyists" keep scorpions as "pets" and therefore scorpion envenomations have been reported in all states. Scorpion venom acts as neurotoxin. It will cause paralysis in the small critters that are the scorpions prey. Localized pain, swelling, and numbness may occur in humans.
Most spiders produce venom that is transmitted through their fangs when they bite. Only 2 types of spiders cause serious problems in humans. Loxosceles reclusa, the brown recluse spider is found throughout most of the US. It likes basements, and was once the scourge of outhouses. Its venom is a tissue toxin. It may cause systemic symptoms such as nausea, malaise, and fever. Blood disorders may occur. Hemolysis (rupture of red blood cells), thrombocytopenia (loss of platelets) and DIC (severe loss of the ability of one's blood to clot) have all been reported. The most common consequence of a brown recluse spider bite is a skin ulcer. This loss of skin and underlying tissue can become quite large. It is very slow to heal and although many treatments are used, none has been shown to be consistently effective. The rare deaths from loxoscelism have occurred in children under seven and in the very old with preexisting medical problems.
Latrodectus mactans, the black widow spider possesses a venom that may cause painful reactions. Chills, fever, nausea and/or vomiting, sweats and elevation of the blood pressure have been observed. Severe muscle spasms may lead to abdominal, chest and back pains. The bite itself is so small that the symptoms may not be attributed to a spider bite. Although distressing, the symptoms are easily treated. Rarely, an anaphylactic allergic reaction to the bite may lead to a fatal outcome.
The hymenoptera include all the social insects: ants, bees, wasps, hornets and yellow jackets. The fire ant bite produces severe pain and itching at the location of the bite. A white pustule may form at the site. If a nest is disturbed, one is likely to suffer many bites. In the very small or weak person, the stress and toxicity of the bites can be lethal. Allergic reactions do occur in some. Secondary bacterial infection may also develop.
Honey bees, bumblebees, africanized (killer) bees, wasps and their brethren all inject a toxin when they sting. Most of the time this is a localized problem. Swelling, pain, redness and itching are immediate and self-limited. Honey and killer bee stinger are barbed and the stinger usually remains. The stinger should be carefully removed. The so-called killer bee's deadly reputation is from the number of stings, not the quality of it's venom. These bees tend to swarm and the poor victim often receives tens or hundreds of stings. The quantity of the venom may prove lethal in small children or those with a weakened cardiovascular system.
A bee or wasp sting may progress over 1 to 1.5 days with increasing localized swelling. This is more likely in the legs. Secondary bacterial infection of hymenoptera stings may occur with fever, increasing redness and tenderness, and red streaks (lymphangitis). Tetanus prophylaxis should be given if the patient has not been immunized in the prior 10 years. Stings in the mouth or throat may cause airway obstruction from localized swelling; bikers beware.
Allergic reactions to insect stings and bites are the real danger. Hives, wheezing, nausea and vomiting, chest pains and low blood pressure may be life threatening. Anaphylactic shock is the term given to this constellation of symptoms. Immediate treatments is necessary. Minutes count. Any patient that presents to the ER with an allergic reaction to a hymenoptera sting will be given treatment and strict post care instructions.
A preloaded adrenalin syringe (Epi-Pen) will be prescribed. It should be used immediately, if the patient receives any subsequent hymenoptera sting. The patient will also be referred to an allergist for specific testing and desensitization therapy. The specific species of insect venom can be identified and a series of allergy shots given. Just as it sounds, desensitization will decrease the risk of a life threatening reaction to insect venom.
Be prepared. Don't wear brightly colored clothes. Avoid applying perfumes when going outdoors.
Don't disturb hymenoptera nests. If you have a known insect allergy, CARRY YOUR EPI-PEN WITH YOU AT ALL TIMES. Stop and smell the roses, but watch out for bees.
Of the hundreds of species of scorpions, only 25 are poisonous to humans. In the US scorpion stings are predominately found in the Southwest. Some "hobbyists" keep scorpions as "pets" and therefore scorpion envenomations have been reported in all states. Scorpion venom acts as neurotoxin. It will cause paralysis in the small critters that are the scorpions prey. Localized pain, swelling, and numbness may occur in humans.
Most spiders produce venom that is transmitted through their fangs when they bite. Only 2 types of spiders cause serious problems in humans. Loxosceles reclusa, the brown recluse spider is found throughout most of the US. It likes basements, and was once the scourge of outhouses. Its venom is a tissue toxin. It may cause systemic symptoms such as nausea, malaise, and fever. Blood disorders may occur. Hemolysis (rupture of red blood cells), thrombocytopenia (loss of platelets) and DIC (severe loss of the ability of one's blood to clot) have all been reported. The most common consequence of a brown recluse spider bite is a skin ulcer. This loss of skin and underlying tissue can become quite large. It is very slow to heal and although many treatments are used, none has been shown to be consistently effective. The rare deaths from loxoscelism have occurred in children under seven and in the very old with preexisting medical problems.
Latrodectus mactans, the black widow spider possesses a venom that may cause painful reactions. Chills, fever, nausea and/or vomiting, sweats and elevation of the blood pressure have been observed. Severe muscle spasms may lead to abdominal, chest and back pains. The bite itself is so small that the symptoms may not be attributed to a spider bite. Although distressing, the symptoms are easily treated. Rarely, an anaphylactic allergic reaction to the bite may lead to a fatal outcome.
The hymenoptera include all the social insects: ants, bees, wasps, hornets and yellow jackets. The fire ant bite produces severe pain and itching at the location of the bite. A white pustule may form at the site. If a nest is disturbed, one is likely to suffer many bites. In the very small or weak person, the stress and toxicity of the bites can be lethal. Allergic reactions do occur in some. Secondary bacterial infection may also develop.
Honey bees, bumblebees, africanized (killer) bees, wasps and their brethren all inject a toxin when they sting. Most of the time this is a localized problem. Swelling, pain, redness and itching are immediate and self-limited. Honey and killer bee stinger are barbed and the stinger usually remains. The stinger should be carefully removed. The so-called killer bee's deadly reputation is from the number of stings, not the quality of it's venom. These bees tend to swarm and the poor victim often receives tens or hundreds of stings. The quantity of the venom may prove lethal in small children or those with a weakened cardiovascular system.
A bee or wasp sting may progress over 1 to 1.5 days with increasing localized swelling. This is more likely in the legs. Secondary bacterial infection of hymenoptera stings may occur with fever, increasing redness and tenderness, and red streaks (lymphangitis). Tetanus prophylaxis should be given if the patient has not been immunized in the prior 10 years. Stings in the mouth or throat may cause airway obstruction from localized swelling; bikers beware.
Allergic reactions to insect stings and bites are the real danger. Hives, wheezing, nausea and vomiting, chest pains and low blood pressure may be life threatening. Anaphylactic shock is the term given to this constellation of symptoms. Immediate treatments is necessary. Minutes count. Any patient that presents to the ER with an allergic reaction to a hymenoptera sting will be given treatment and strict post care instructions.
A preloaded adrenalin syringe (Epi-Pen) will be prescribed. It should be used immediately, if the patient receives any subsequent hymenoptera sting. The patient will also be referred to an allergist for specific testing and desensitization therapy. The specific species of insect venom can be identified and a series of allergy shots given. Just as it sounds, desensitization will decrease the risk of a life threatening reaction to insect venom.
Be prepared. Don't wear brightly colored clothes. Avoid applying perfumes when going outdoors.
Don't disturb hymenoptera nests. If you have a known insect allergy, CARRY YOUR EPI-PEN WITH YOU AT ALL TIMES. Stop and smell the roses, but watch out for bees.
Friday, April 9, 2010
Achooo
Springtime. Pollen fills the air and causes congestion, sneezing, and watery eyes. This should be a job for primary care, but no, the ER treats even seasonal allergies. I had an elderly woman arrive by ambulance because of difficulty breathing. Her only symptom was nasal congestion. Earlier this week, "Robin" my PA, examined a boy with allergies because the meds prescribed by his pediatrician 12 hours before had not cured his stuffy nose and itchy eyes.
Allergic rhinitis and allergic conjunctivitis are the medical terms for these annoying complaints. Pollen, mold spores, animal dander and other organic substances can trigger allergic symptoms. The biology is rather simple. Allergens cause the immune system to produce IgE. This is a type of immune globulin. IG's are proteins manufactured by different types of white blood cells. They enhance or modulate our immune response to foreign proteins. IgE triggers the release of histamine by immune cells. Histamine causes the swelling, itching, and general misery of seasonal allergies.
Diphenhydramine (Bendaryl and others) blocks the release of histamine. This leads to less dripping and itching but is accompanied by dry mouth, sleepiness and other annoying side effects. Newer antihistamines have less sedation. Leukotriene inhibitors (Singulair) are also effective in blocking the symptoms of seasonal allergies and asthma. Steroids are very effective in treating allergies. Usually used as a nasal inhaler, they have mild side effects and are applied at the root of the problems. There are also eye drops that can alleviate the symptoms of allergic conjunctivitis.
While we are considering the specific ER problems of spring, let's talk about rashes and bugs. The emergence of greenery inevitably leads to contact dermatitis. Poison ivy, oak and sumac are plants that contain an oil that triggers the formation of vessicles (little blisters). Urushiol is the chemical present in poison ivy that acts as a vessicant. Small blisters (vessicles) accompanied by itching and weeping result from exposure to urushiol. This is not a true allergy, but some are more sensitive than others. If someone says they are "immune" to PI, challenge them to rub their privates with poison ivy. This dare works best in the barroom setting.
Sun exposure presents an addition cause of rashes. Sunburn is obvious but the sunlight can also trigger photodermatitis. Many common medications, lotions (including sunblock, and toiletries) may be activated by ultraviolet radiation in sunlight to cause mild to severe rashes. The printed material supplied by pharmacists give some warning of potential photosensitizing medications. Avoidance of sun exposure, not simply applying sunscreen, is the only effective preventative.
Arthropods have caused disease and misery to humans and all terrestrial vertebrates since our ancestors crawled out of the sea. Mosquitoes, flies, fleas and ticks torture us like the plagues of Exodus in the bible. Black death, malaria, sleeping sickness, oriental sores, yellow fever and many other diseases are transmitted by the bite of an arthropod. The current "plague" of Lyme disease is due to Borrrelia Burgdorferi, a spirochete bacteria. The vector (carrier) is the Ixodes tick.
The mildest reaction to an arthropod bite is localized swelling and itching. This is caused by proteins in the bugs' saliva. Applying cold or topical cortisone creams quickly alleviate the problem. Ticks attach themselves to their hosts and leisurely partake of a meal of blood. While dining, they pass on the microorganisms that cause Lyme disease, Rocky Mountain spotted fever, Erlichosis and other infections. Mosquitoes transmit malaria and yellow fever while sucking our blood. A tick bite can lead to tick paralysis. This is an immune response to the tick bite that causes an ascending loss of muscle control. The only treatment necessary is to remove the tick.
Lyme disease has become common in much of the United States. The earliest cases were described and subsequently named for Old Lyme, Connecticut. The Ixodes tick can transmit the infection after 24-72 hours of being attached to a human. A transient rash, erythema migrans, may be noticed in the area of the bite. Fever, chills, and joint aches are common early in the infection. If not recognized and treated, Lyme disease can progress to inflammation and damage to the joints, especially the knees. Injury to the nerves can lead to Bell's palsy, a loss of function of the facial muscles. Meningitis and encephalitis may also be caused by the Borrelia spirochete.
Heightened awareness, early recognition and treatment with antibiotics are the keys to treating Lyme disease. There is currently no effective, safe and approved vaccine, for humans, to prevent Lyme disease. Prevention is best with regards to arthropod spread diseases. Liberal use of insect repellents, avoidance of ticks and mosquitoes and examination after being in tick prone areas are very effective. Wear light colored clothes. Tuck your trousers into your socks. Spray your clothing with DEET containing insect repellents. Remember that the Ixodes tick is the size of the period at the end of this sentence.
Enjoy the spring. Your dedicated ER staff is ready to treat the sneezes, wheezes, itches and twitches that result from the great outdoors. Gesundheit!
Allergic rhinitis and allergic conjunctivitis are the medical terms for these annoying complaints. Pollen, mold spores, animal dander and other organic substances can trigger allergic symptoms. The biology is rather simple. Allergens cause the immune system to produce IgE. This is a type of immune globulin. IG's are proteins manufactured by different types of white blood cells. They enhance or modulate our immune response to foreign proteins. IgE triggers the release of histamine by immune cells. Histamine causes the swelling, itching, and general misery of seasonal allergies.
Diphenhydramine (Bendaryl and others) blocks the release of histamine. This leads to less dripping and itching but is accompanied by dry mouth, sleepiness and other annoying side effects. Newer antihistamines have less sedation. Leukotriene inhibitors (Singulair) are also effective in blocking the symptoms of seasonal allergies and asthma. Steroids are very effective in treating allergies. Usually used as a nasal inhaler, they have mild side effects and are applied at the root of the problems. There are also eye drops that can alleviate the symptoms of allergic conjunctivitis.
While we are considering the specific ER problems of spring, let's talk about rashes and bugs. The emergence of greenery inevitably leads to contact dermatitis. Poison ivy, oak and sumac are plants that contain an oil that triggers the formation of vessicles (little blisters). Urushiol is the chemical present in poison ivy that acts as a vessicant. Small blisters (vessicles) accompanied by itching and weeping result from exposure to urushiol. This is not a true allergy, but some are more sensitive than others. If someone says they are "immune" to PI, challenge them to rub their privates with poison ivy. This dare works best in the barroom setting.
Sun exposure presents an addition cause of rashes. Sunburn is obvious but the sunlight can also trigger photodermatitis. Many common medications, lotions (including sunblock, and toiletries) may be activated by ultraviolet radiation in sunlight to cause mild to severe rashes. The printed material supplied by pharmacists give some warning of potential photosensitizing medications. Avoidance of sun exposure, not simply applying sunscreen, is the only effective preventative.
Arthropods have caused disease and misery to humans and all terrestrial vertebrates since our ancestors crawled out of the sea. Mosquitoes, flies, fleas and ticks torture us like the plagues of Exodus in the bible. Black death, malaria, sleeping sickness, oriental sores, yellow fever and many other diseases are transmitted by the bite of an arthropod. The current "plague" of Lyme disease is due to Borrrelia Burgdorferi, a spirochete bacteria. The vector (carrier) is the Ixodes tick.
The mildest reaction to an arthropod bite is localized swelling and itching. This is caused by proteins in the bugs' saliva. Applying cold or topical cortisone creams quickly alleviate the problem. Ticks attach themselves to their hosts and leisurely partake of a meal of blood. While dining, they pass on the microorganisms that cause Lyme disease, Rocky Mountain spotted fever, Erlichosis and other infections. Mosquitoes transmit malaria and yellow fever while sucking our blood. A tick bite can lead to tick paralysis. This is an immune response to the tick bite that causes an ascending loss of muscle control. The only treatment necessary is to remove the tick.
Lyme disease has become common in much of the United States. The earliest cases were described and subsequently named for Old Lyme, Connecticut. The Ixodes tick can transmit the infection after 24-72 hours of being attached to a human. A transient rash, erythema migrans, may be noticed in the area of the bite. Fever, chills, and joint aches are common early in the infection. If not recognized and treated, Lyme disease can progress to inflammation and damage to the joints, especially the knees. Injury to the nerves can lead to Bell's palsy, a loss of function of the facial muscles. Meningitis and encephalitis may also be caused by the Borrelia spirochete.
Heightened awareness, early recognition and treatment with antibiotics are the keys to treating Lyme disease. There is currently no effective, safe and approved vaccine, for humans, to prevent Lyme disease. Prevention is best with regards to arthropod spread diseases. Liberal use of insect repellents, avoidance of ticks and mosquitoes and examination after being in tick prone areas are very effective. Wear light colored clothes. Tuck your trousers into your socks. Spray your clothing with DEET containing insect repellents. Remember that the Ixodes tick is the size of the period at the end of this sentence.
Enjoy the spring. Your dedicated ER staff is ready to treat the sneezes, wheezes, itches and twitches that result from the great outdoors. Gesundheit!
Friday, April 2, 2010
The Big Hurt
This epistle (it's good Friday) will consider blunt trauma to the torso. The trunk contains the cardiac, pulmonary, renal and gastrointestinal organs. It is also where the great vessels reside. The aorta and its main branches and the superior and inferior vena cava all are found in the trunk. Unlike our distant cousins such as turtles and armadillos, humans are poorly shielded from direct injuries. The rib cage offers little protection from baseball bats, falls or ejections from moving vehicles.
The main forces that lead to blunt trauma are deceleration and kinetic energy. Solid organs such as the liver, spleen, and kidneys tend to crack when they absorb enough energy (Louisville slugger to the belly or back). When the body is moving and stops abruptly (inertia again), the solid organs continue to move. If the deceleration forces are strong, the vascular attachments of the solid organs can be torn.
The lungs can suffer several types of injuries from blunt trauma. Increased pressure in the air filled lungs can cause them to "pop", or a broken rib can lacerate the lung. The result is the same, a pneumothorax. The lungs fill by the negative pressure from the contraction of the diaphragm and the other muscles of respiration. With the leaking of air from the lung into the chest cavity, the lung collapses like a deflated balloon. If air enters the chest cavity with a breath and can't exit, the pressure in the chest grows. This is known as a tension pneumothorax. If not treated rapidly, the ever increasing pressure will displace the heart, compress the intact lung, and obstruct the flow in the great vessels. The key is recognition by the EMS or ER personnel. A large needle is inserted through the chest wall, and a loud whoosh of escaping air is heard.
Tearing or shearing of large vessels in the chest can cause a hemothorax. As the chest fills with blood, the lungs are unable to inflate. A chest tube (or 2) is inserted to drain the blood and reestablish the negative pressure in the chest so that the lungs can expand.
The lungs can also be bruised by blunt trauma. A pulmonary contusion, with blood in the airsacs (alveoli), causes a loss of air exchange in the are of the contusion. The trachea, bronchi and pulmonary blood vessels are all vulnerable to deceleration forces and these injuries may prove fatal. We have all seen the ER doc on TV ask for a scalpel and rib spreader. An emergency thoracotomy is usually an exercise in frustration. Unlike the patient on TV, these patients infrequently survive, despite the heroic efforts of the trauma team.
Blunt trauma to the front of the chest can injure the heart. Commotio cordis is the medical term for sudden death from a blow to the anterior chest. The little leaguer who drops dead after being struck by a ball is a victim of this fatal disruption in the electrical activity of the heart. Portable defibrillators may decrease these tragic deaths from arrythmias. The heart can be bruised (cardiac contusion) from blunt force trauma to the chest. The injured heart muscle reacts similarly to a heart attack. Irregular rhythyms and impaired pumping by the heart can be dangerous.
The abdomen is often injured in blunt force trauma. The solid organs have some protection from the lower rib cage. The gas filled stomach and intestines may rupture from the sudden increased pressure in impact or deceleration events. The urine filled bladder is also prone to rupture. Tearing of vessels and intestines are common in high speed deceleration accidents. Stomach acid, digestive enzymes, urine, bacteria from fecal material and blood; that's the recipe for infections and sometimes late deaths from severe trauma.
CT scans and ultrasound along with careful history and physical examination are the tools of the trauma team. EKG, labs, and plain x-ray also are utilized. The "pan scan" is a CT that examines the patient from the top of the head to the base of the pelvis. It can be performed quite quickly and helps guide the trauma team to plan further testing or treatment. I would be remiss if I didn't point out that the radiation dose from a pan scan is estimated to increase the patient's lifetime risk of cancer by 1-2%.
Trauma centers have been established and certified by the American College of Surgeons. These hospitals are labelled level one to level three. I work at a level three regional trauma center. The ER docs are all certified in ATLS (advanced trauma life support). There is off-site surgical back up. My role is to rapidly diagnosis and treat or refer to a higher acuity trauma center. A level one trauma center is usually located in a large teaching hospital. All of the surgical subspecialties are available. Specialized ground and helicopter transport are utilized to get the trauma patient to the closest and most appropriate trauma center. EMS personnel are trained to provide triage. This assigns the injured patient a number corresponding to the severity of their injuries. In an accident that involves many victims, it is crucial that good triage maximizes the chances of survival for the injured.
Wear appropriate protective gear. Use your lap and shoulder belts. Drive sober and defensively.
For my young male friends, try and use the frontal lobes of your brain and ignore the testosterone infused urges of your pals.
The main forces that lead to blunt trauma are deceleration and kinetic energy. Solid organs such as the liver, spleen, and kidneys tend to crack when they absorb enough energy (Louisville slugger to the belly or back). When the body is moving and stops abruptly (inertia again), the solid organs continue to move. If the deceleration forces are strong, the vascular attachments of the solid organs can be torn.
The lungs can suffer several types of injuries from blunt trauma. Increased pressure in the air filled lungs can cause them to "pop", or a broken rib can lacerate the lung. The result is the same, a pneumothorax. The lungs fill by the negative pressure from the contraction of the diaphragm and the other muscles of respiration. With the leaking of air from the lung into the chest cavity, the lung collapses like a deflated balloon. If air enters the chest cavity with a breath and can't exit, the pressure in the chest grows. This is known as a tension pneumothorax. If not treated rapidly, the ever increasing pressure will displace the heart, compress the intact lung, and obstruct the flow in the great vessels. The key is recognition by the EMS or ER personnel. A large needle is inserted through the chest wall, and a loud whoosh of escaping air is heard.
Tearing or shearing of large vessels in the chest can cause a hemothorax. As the chest fills with blood, the lungs are unable to inflate. A chest tube (or 2) is inserted to drain the blood and reestablish the negative pressure in the chest so that the lungs can expand.
The lungs can also be bruised by blunt trauma. A pulmonary contusion, with blood in the airsacs (alveoli), causes a loss of air exchange in the are of the contusion. The trachea, bronchi and pulmonary blood vessels are all vulnerable to deceleration forces and these injuries may prove fatal. We have all seen the ER doc on TV ask for a scalpel and rib spreader. An emergency thoracotomy is usually an exercise in frustration. Unlike the patient on TV, these patients infrequently survive, despite the heroic efforts of the trauma team.
Blunt trauma to the front of the chest can injure the heart. Commotio cordis is the medical term for sudden death from a blow to the anterior chest. The little leaguer who drops dead after being struck by a ball is a victim of this fatal disruption in the electrical activity of the heart. Portable defibrillators may decrease these tragic deaths from arrythmias. The heart can be bruised (cardiac contusion) from blunt force trauma to the chest. The injured heart muscle reacts similarly to a heart attack. Irregular rhythyms and impaired pumping by the heart can be dangerous.
The abdomen is often injured in blunt force trauma. The solid organs have some protection from the lower rib cage. The gas filled stomach and intestines may rupture from the sudden increased pressure in impact or deceleration events. The urine filled bladder is also prone to rupture. Tearing of vessels and intestines are common in high speed deceleration accidents. Stomach acid, digestive enzymes, urine, bacteria from fecal material and blood; that's the recipe for infections and sometimes late deaths from severe trauma.
CT scans and ultrasound along with careful history and physical examination are the tools of the trauma team. EKG, labs, and plain x-ray also are utilized. The "pan scan" is a CT that examines the patient from the top of the head to the base of the pelvis. It can be performed quite quickly and helps guide the trauma team to plan further testing or treatment. I would be remiss if I didn't point out that the radiation dose from a pan scan is estimated to increase the patient's lifetime risk of cancer by 1-2%.
Trauma centers have been established and certified by the American College of Surgeons. These hospitals are labelled level one to level three. I work at a level three regional trauma center. The ER docs are all certified in ATLS (advanced trauma life support). There is off-site surgical back up. My role is to rapidly diagnosis and treat or refer to a higher acuity trauma center. A level one trauma center is usually located in a large teaching hospital. All of the surgical subspecialties are available. Specialized ground and helicopter transport are utilized to get the trauma patient to the closest and most appropriate trauma center. EMS personnel are trained to provide triage. This assigns the injured patient a number corresponding to the severity of their injuries. In an accident that involves many victims, it is crucial that good triage maximizes the chances of survival for the injured.
Wear appropriate protective gear. Use your lap and shoulder belts. Drive sober and defensively.
For my young male friends, try and use the frontal lobes of your brain and ignore the testosterone infused urges of your pals.
Subscribe to:
Posts (Atom)