Diabetes Mellitus comes in two forms. Type 1 diabetes usually begins in children or young adults. It is a failure of insulin production by islet cells in the pancreas. Type 1 diabetics require insulin to survive. At this time there is excellent treatment but no cure for type 1 diabetes. Type 2 diabetes was in the past referred to as adult onset diabetes. Obesity, advanced age and lack of exercise are risk factors. As obesity has become an "epidemic" in the USA, the incidence of type 2 diabetes has increased, even among children. Type 2 diabetics produce insulin but the amount produced is inadequate for the body needs. Target tissue, such as muscles, and fat become resistant to the effects of insulin in type 2 diabetics.
As an ER doc I have seen children who present with what seems to be viral gastroenteritis. Persistent vomiting, and clear signs of dehydration are evident. The child has an abnormally high respiratory rate. The lab tests tell the tale. The child has an elevated glucose, low bicarb and elevated serum acetone. This is the typical picture of a child with new type 1 DM. The child and his or her family will never be the same. This is a life long condition.
My friend Ken developed DM when we were 8 years old. The monitoring of glucose levels, at that time, was by urine testing. I was given a basic understanding of the signs of high and low glucose levels. Hypoglycemia, low blood sugar can be obvious or subtle. Ken and I were playing a board game at my house (it was the early sixties, no electronic games). He started acting odd. He played poorly and then turned over the board. I asked him to leave. As he tried to ride his bike up the street, it hit me that he was having an insulin reaction. I chased after him, dragging him back to my house and force fed him OJ with sugars added. He rapidly returned to his usual affable self.
In the past months I had three patients who demonstrate the complexities and potentially devastating effects of DM and it's treatment. Frequent monitoring (blood testing), multiple injections and or pills, and constant attention to diet and exercise is daunting. Long term complications of DM are manifested by kidney failure, vascular disease, visual problems, and nerve damage. Diabetes is the leading cause of both kidney failure and blindness in the USA.
Vascular disease increases the diabetic's risk for heart attack, stroke and peripheral vascular disease.
The first patient in my diabetic trio was a 70 year woman who's presenting complaint was weakness. Her symptoms had progressed over 2-3 days. She was somewhat confused. Her attentive family gave her medical history and described her rather sudden change in health. They also brought all her medications. The nurses had done a capillary blood sugar immediately and it was 460. Her physical exam was remarkable for generalized weakness, clear lungs with a respiratory rate of 28 and disorientation to date and recent events. She took oral medication for her type 2 DM. I noticed that the amount of metformin she was taking was above the usual recommended amount. An arterial blood sample revealed a pH of 6.67. Normal pH is 7.4 and as this is a logarithmic scale, her pH showed a profound acidosis. Her lactic acid level was 15 (normal is 2 or less). As I began treating her with insulin, IV fluids and Bicarb, I admitted her to the ICU and called the intensivist. I gave him her history, physical and labs. His comment was that with a pH of 6.67 she should be dead. Luckily she recovered completely. Her life threatening lactic acidosis was most likely caused by the metformin she took for her DM.
Patient 2 and 3 came to the ER the same night. Patient 2 was a type 1 diabetic who worked construction. This has been an especially hot and humid summer and he was working outdoors doing heavy labor. Low blood pressure, dry skin and mucous membranes, and tachycardia, prompted rapid infusions of IV fluids. Even after 3 liters of IV fluid, the patient had not produced any urine. A catheter was placed in his bladder and only a trickle of urine was obtained. The lab tests showed a critically elevated BUN and creatinine. My patient had kidney failure. This gentleman was an undocumented immigrant. He was an honest and hard worker. He supported his family. He obtained insulin by occasionally seeing a doctor in a local clinic. His lack of insurance precluded him from getting the close supervision and support that might have prevented this complication of DM. The heat and hard labor had sealed his kidneys' fate.
My third diabetic patient in this tale, was a type 1 diabetic who had insurance, a good job, a supportive family and access to good health care. This gentleman was in mild ketoacidosis and was very hypertensive. He had not felt well for a few days. He had little appetite, nausea and some vomiting. His response to these symptoms was to stop taking his insulin and blood pressure medications. This is an all-to-common reaction by diabetics. No eating=no need for insulin. The treatment was not difficult. Insulin, IV fluids, blood pressure control and admission to the hospital. The difficult aspect of his care was convincing him that he needed in-patient treatment. "Can't I just go home?" His wife and I were able to get him to agree to being admitted. He thanked me and assured me that in the future, he would do better at managing his diabetes.
The incidence of diabetes in patient who go to ER's, is much higher than the rate in the overall population. Poor compliance with treatment is rife. As a person with obsessive-compulsive tendencies, I would like to think that the frequent finger sticks, strick diet, and need to keep one's weight stable would be easy. The reality is that managing DM is very time consuming. Diabetics want to be just like their non-diabetic friends. They want to have fun, eat junk food, have an alcoholic beverage (or two), and be one of the guys.
No lessons will be offered in this blog. Diabetes, with all varying forms, and both short and long term complications, does not lend itself to simple fixes. I would encourage everyone with diabetes to see their physician regularly, take their medications as prescribed, and seek help early with any changes in their health.
Friday, July 23, 2010
Saturday, July 17, 2010
Reality Bites
No, this is not another blog about dental problems. I wish to comment on the egregiously unrealistic TV show "Untold stories of the ER". Today is another in an endless string of hot days. The world's oldest ER doc and his faithful hound do not take well to the heat. The lady of the house is visiting family in NY. After catching up on my reading and correspondence, and being bored watching baseball, I did a little channel surfing. An alleged ER doc with the worst hair piece I have seen in a decade, came into my den via "untold stories...". He was comparing moving a morbidly obese patient, to a veterinarian hoisting a horse.
TV dramas that depict activities in an ER are bad enough. Overly attractive, unbelievably self absorbed, and laughably over-sexed, these series are at least sold as fiction. Untold stories purports to represent my life's calling. Every ER doc, nurse, PA, and tech has a catalog of comic, tragic and mysterious tales of the ER that would make for better entertainment than "untold".
I sat in my chair mulling whether the guy with the bad rug was an awful actor or an ER doc desperately trying to achieve his 15 minutes of fame. My own pate is mostly gray and sports a high forehead and ever expanding bald spot. My head bears an uncanny resemblance to the tonsured cranium of a medieval monk. Middle age, male pattern baldness and 30 plus years of nights in the ER have shaped my melon. She, who must be obeyed, says that my bald spot is sexy. My lovely wife often favors me with a kiss on my hairless skull. My bald spot also acts as an efficient radiator, as I perspire exclusively in this area, when I eat hot peppers.
A recent documentary series has debuted that follows the exploits of health care workers at Harvard Medical School affiliated hospitals. This is a legitimate effort to portray medicine truthfully. My ER, in a community hospital, is a far cry from the tertiary care hospital shown in "Boston Medical". I don't have layers of residents and students and attending physicians from all necessary specialties available to me 24/7. My reality is that I have to stabilize and transfer patients to these wonderful meccas of medicine.
Some recent transfers included a teenager involved in a MVA. This patient had a midshaft fracture of the femur. The on-call orthopedic surgeon didn't wish to treat this patient. My partner had to arrange a transfer. I had to transfer a middle aged patient who had been admitted with an unexplained syncopal episode. When this person had a grand mal seizure, a CT showed a previously undiagnosed brain tumor. The neurosurgeon at our hospital agreed to treat this patient but the intensivist said no. The ICU doctor said that the neurosurgeon couldn't be relied on to be available in a crisis, and therefore the patient was shipped to one of those wonderful hospitals seen on "Boston Med".
If we could magically rescind the requirements of various state and federal privacy acts, then we could have a "real" ER show. I would wear the latest high tech mini camera. Nothing would be edited. Digitally disimpacting an elderly woman's rectum in streaming video from the "belly of the beast". Now that would be reality TV.
TV dramas that depict activities in an ER are bad enough. Overly attractive, unbelievably self absorbed, and laughably over-sexed, these series are at least sold as fiction. Untold stories purports to represent my life's calling. Every ER doc, nurse, PA, and tech has a catalog of comic, tragic and mysterious tales of the ER that would make for better entertainment than "untold".
I sat in my chair mulling whether the guy with the bad rug was an awful actor or an ER doc desperately trying to achieve his 15 minutes of fame. My own pate is mostly gray and sports a high forehead and ever expanding bald spot. My head bears an uncanny resemblance to the tonsured cranium of a medieval monk. Middle age, male pattern baldness and 30 plus years of nights in the ER have shaped my melon. She, who must be obeyed, says that my bald spot is sexy. My lovely wife often favors me with a kiss on my hairless skull. My bald spot also acts as an efficient radiator, as I perspire exclusively in this area, when I eat hot peppers.
A recent documentary series has debuted that follows the exploits of health care workers at Harvard Medical School affiliated hospitals. This is a legitimate effort to portray medicine truthfully. My ER, in a community hospital, is a far cry from the tertiary care hospital shown in "Boston Medical". I don't have layers of residents and students and attending physicians from all necessary specialties available to me 24/7. My reality is that I have to stabilize and transfer patients to these wonderful meccas of medicine.
Some recent transfers included a teenager involved in a MVA. This patient had a midshaft fracture of the femur. The on-call orthopedic surgeon didn't wish to treat this patient. My partner had to arrange a transfer. I had to transfer a middle aged patient who had been admitted with an unexplained syncopal episode. When this person had a grand mal seizure, a CT showed a previously undiagnosed brain tumor. The neurosurgeon at our hospital agreed to treat this patient but the intensivist said no. The ICU doctor said that the neurosurgeon couldn't be relied on to be available in a crisis, and therefore the patient was shipped to one of those wonderful hospitals seen on "Boston Med".
If we could magically rescind the requirements of various state and federal privacy acts, then we could have a "real" ER show. I would wear the latest high tech mini camera. Nothing would be edited. Digitally disimpacting an elderly woman's rectum in streaming video from the "belly of the beast". Now that would be reality TV.
Friday, July 16, 2010
Toothache
I am one day post-op from periodontal surgery. The left lower quadrant of my face most resembles a chipmunk toting nuts. The swelling and pain leads me to a discussion of dental issues in the ER.
Toothache is a common presenting complaint, especially on the night shift. The humanitarian in me acknowledges that pain, that keeps a patient from sleeping, is a good reason to visit the ER. The cynicism developed in 30 plus years in the ER recognizes that drug addicts tend to have poor oral hygiene and rarely have dental insurance. Meth mouth (methamphetamine) is a myth, but flossing and brushing is not high on the priority list for drug abusers.
My tooth hurts. Simple enough. The human mouth has 32 teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars. The mouth is also home to gums, the tongue and a cornucopia of bacteria. There is a good reason why human bites are among the most-likely-to-get-infected among all mammalian bites.
Diets high in sugar, acidic drinks (colas), and lack of personal or professional dental care inevitably leads to caries, abscesses and gingivitis. The mouth is well supplied with pain sensing nerve fibers. Add the Saturday night alcohol and testosterone fueled mayhem culminating in oral trauma, and we have lots of ER visits for mouth problems.
I am not a dentist. Some of my best friends are dentists. I have tremendous respect for the dental profession. ER docs do not want to play dentist. We make sure that the problem is not a potentially life threatening infection such as Ludwig's angina (an infection that starts in the mouth but spreads through the neck and into the chest). The immunocompromised patient who has HIV, is undergoing cancer treatment, is taking steroids for a medical condition, or has a congenital defect in immunity, may also have a tooth ache that is a true emergency.
Two severe oral infections may present as mouth pain. NUG (necrotizing ulcerative gingivitis) and herpes gingivastomatitis are true oral emergencies. The treatment of which usually begins in the ER. Manifestations of systemic diseases may also present with mouth pain. Any ulcers, blisters or purpuric lesions should trigger a thorough evaluation of the patient for diseases such a Stevens-Johnson, bullous pemphigous, blood dyscrasias and rheumatological illnesses.
Oral trauma is another source of concern and need for diligence by the ER staff. Unlike our friends, the sharks, humans cannot grow new teeth. Even a child's deciduous (baby) teeth play an important role in oral health and later mouth development. Few ER's have oral surgical back-up on a consistent basis. Prepackaged kits exist that aid the ER staff to provide temporizing measures in managing damaged or avulsed teeth.
Lack of professional dental care is epidemic among adults in the USA. Few people have dental insurance. Emergency medicine training gives very little time to the evaluation and treatment of oral emergencies. I admit that as in most ER's, PA's see the vast majorities of patients with toothache as the presenting complaint. As with so many other problems in the health care system, the ER acts as a safety net.
As my dentist tells me: don't eat sugary treats or foods that stick to your teeth; avoid carbonated beverages; floss once a day; brush after eating; have professional dental cleanings every 6 months. SMILE
Toothache is a common presenting complaint, especially on the night shift. The humanitarian in me acknowledges that pain, that keeps a patient from sleeping, is a good reason to visit the ER. The cynicism developed in 30 plus years in the ER recognizes that drug addicts tend to have poor oral hygiene and rarely have dental insurance. Meth mouth (methamphetamine) is a myth, but flossing and brushing is not high on the priority list for drug abusers.
My tooth hurts. Simple enough. The human mouth has 32 teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars. The mouth is also home to gums, the tongue and a cornucopia of bacteria. There is a good reason why human bites are among the most-likely-to-get-infected among all mammalian bites.
Diets high in sugar, acidic drinks (colas), and lack of personal or professional dental care inevitably leads to caries, abscesses and gingivitis. The mouth is well supplied with pain sensing nerve fibers. Add the Saturday night alcohol and testosterone fueled mayhem culminating in oral trauma, and we have lots of ER visits for mouth problems.
I am not a dentist. Some of my best friends are dentists. I have tremendous respect for the dental profession. ER docs do not want to play dentist. We make sure that the problem is not a potentially life threatening infection such as Ludwig's angina (an infection that starts in the mouth but spreads through the neck and into the chest). The immunocompromised patient who has HIV, is undergoing cancer treatment, is taking steroids for a medical condition, or has a congenital defect in immunity, may also have a tooth ache that is a true emergency.
Two severe oral infections may present as mouth pain. NUG (necrotizing ulcerative gingivitis) and herpes gingivastomatitis are true oral emergencies. The treatment of which usually begins in the ER. Manifestations of systemic diseases may also present with mouth pain. Any ulcers, blisters or purpuric lesions should trigger a thorough evaluation of the patient for diseases such a Stevens-Johnson, bullous pemphigous, blood dyscrasias and rheumatological illnesses.
Oral trauma is another source of concern and need for diligence by the ER staff. Unlike our friends, the sharks, humans cannot grow new teeth. Even a child's deciduous (baby) teeth play an important role in oral health and later mouth development. Few ER's have oral surgical back-up on a consistent basis. Prepackaged kits exist that aid the ER staff to provide temporizing measures in managing damaged or avulsed teeth.
Lack of professional dental care is epidemic among adults in the USA. Few people have dental insurance. Emergency medicine training gives very little time to the evaluation and treatment of oral emergencies. I admit that as in most ER's, PA's see the vast majorities of patients with toothache as the presenting complaint. As with so many other problems in the health care system, the ER acts as a safety net.
As my dentist tells me: don't eat sugary treats or foods that stick to your teeth; avoid carbonated beverages; floss once a day; brush after eating; have professional dental cleanings every 6 months. SMILE
Friday, July 9, 2010
Pressure
Hypertension is a common and, at least initially, symptom free disease. Lay people say they have high blood pressure or "a touch of pressure". Inexpensive home blood pressure monitors have become widely used. I hate these monitors. A seemingly universal misconception is that high blood pressure is the equivalent of the psychological feeling of being pressured. Work, family or money stressors lead my soon-to-be patients to check their BP. An elevated reading sends them to the ER in a panic.
Hypertension is a complex disease. Genetic, dietary and anatomic factors may all contribute to the development of HTN. There are no symptoms of early HTN. Patients relate elevated BP with headaches, nose bleeds and anxiety. This is a false correlation. The blood pressure measurement taken from the arm is not the level in the entire body. The arteries that supply the brain have the ability to autoregulate. The BP in the brain is not the same as in the arm.
Headaches may be symptomatic of advanced and prolonged HTN. The nose is not a blow out valve. If your nose is bleeding it is not because your BP is elevated.
The measurement of blood pressure is most accurately obtained with a blood pressure cuff, stethoscope and a well trained ear. The cuff is inflated to a pressure that must be above the patient's systolic pressure. The 120/80 is the reading of the systolic/diastolic pressure in the arteries. Systole is the active contracting phase of the ventricles of the heart. The left ventricle pumps blood into the aorta and subsequently to all the arteries, arterioles and capillaries in the body. The lower number, diastolic pressure, is the reading during the filling phase of the ventricle.
Arteries have three layers that allow them to expand and contract. Aging leads to a decreased elasticity of the arterial wall. Hardening of the arteries is the commonly used term for this decreased flexibility. Aging, increased weight, high salt intake, lack of exercise and stress may all lead to increased blood pressure.
Blood pressure readings are related to the auscultation of the Korotkoff sounds. After pumping up the blood pressure cuff, it is slowly deflated. One listens with a stethoscope over the brachial artery and notes the reading when a "pulse" is heard. The first Korotkoff sound is the systolic blood pressure. As the cuff continues to be slowly deflated, the reading when the sound stops (some use the reading when the sound is muffled) is recorded as the diastolic pressure. This takes some skill. Using too much force, with the stethoscope, over the artery can effect the reading. If the Korotkoff sounds are heard with the cuff inflated it means that the initial cuff pressure was lower than the patient's systolic BP. It is necessary to totally deflate the cuff, wait a few minutes and inflate the cuff to a higher initial pressure.
Electronic BP monitors tend to read higher than BP's done by hand. Like all measuring devices, BP monitors need to be regularly calibrated. The size of the cuff used is also important. A health care worker will use the correct sized cuff for the diameter of the patient's arm. A too small cuff will give a falsely higher reading. The one-size-fits-all BP monitors are often too small for our rapidly "expanding" patient population.
One of my partners treated a patient who's presenting complaint was that he couldn't find a primary care physician (PCP). The patient has HTN and had been started on meds during a prior ER visit. His prescriptions had run out. The ER as primary care center is an issue the continues to grow in importance. When a patient checks their BP and gets a high reading they rush and call their PCP. The advice is usually to go to the ER for further evaluation.
HTN was once referred to as the silent killer. Because HTN causes no symptoms, the initial presentation could be when the end organ damage has occurred. Prolonged untreated HTN strains the heart. The left ventricle compensates for elevated systolic BP by getting thicker. Hypertrophy of the muscle of the left ventricle will eventually lead to heart failure or heart attack. The brain's autoregulatory ability will, over time, fail and stroke will be the result. The kidneys are involved in blood pressure regulation. These vitals organs will also be damaged by long standing HTN.
I know that this will sound familiar but here goes: Maintain a healthy weight. Exercise regularly. Limit your salt intake. See your PCP for regular check ups. Take your blood pressure meds as prescribed. HTN is a chronic but manageable disease. Do not stop taking your BP meds without getting your doctor's OK. Normal BP for an adult is based on recommendations from the American Heart Association. Visit their website for current advisories.
Hypertension is a complex disease. Genetic, dietary and anatomic factors may all contribute to the development of HTN. There are no symptoms of early HTN. Patients relate elevated BP with headaches, nose bleeds and anxiety. This is a false correlation. The blood pressure measurement taken from the arm is not the level in the entire body. The arteries that supply the brain have the ability to autoregulate. The BP in the brain is not the same as in the arm.
Headaches may be symptomatic of advanced and prolonged HTN. The nose is not a blow out valve. If your nose is bleeding it is not because your BP is elevated.
The measurement of blood pressure is most accurately obtained with a blood pressure cuff, stethoscope and a well trained ear. The cuff is inflated to a pressure that must be above the patient's systolic pressure. The 120/80 is the reading of the systolic/diastolic pressure in the arteries. Systole is the active contracting phase of the ventricles of the heart. The left ventricle pumps blood into the aorta and subsequently to all the arteries, arterioles and capillaries in the body. The lower number, diastolic pressure, is the reading during the filling phase of the ventricle.
Arteries have three layers that allow them to expand and contract. Aging leads to a decreased elasticity of the arterial wall. Hardening of the arteries is the commonly used term for this decreased flexibility. Aging, increased weight, high salt intake, lack of exercise and stress may all lead to increased blood pressure.
Blood pressure readings are related to the auscultation of the Korotkoff sounds. After pumping up the blood pressure cuff, it is slowly deflated. One listens with a stethoscope over the brachial artery and notes the reading when a "pulse" is heard. The first Korotkoff sound is the systolic blood pressure. As the cuff continues to be slowly deflated, the reading when the sound stops (some use the reading when the sound is muffled) is recorded as the diastolic pressure. This takes some skill. Using too much force, with the stethoscope, over the artery can effect the reading. If the Korotkoff sounds are heard with the cuff inflated it means that the initial cuff pressure was lower than the patient's systolic BP. It is necessary to totally deflate the cuff, wait a few minutes and inflate the cuff to a higher initial pressure.
Electronic BP monitors tend to read higher than BP's done by hand. Like all measuring devices, BP monitors need to be regularly calibrated. The size of the cuff used is also important. A health care worker will use the correct sized cuff for the diameter of the patient's arm. A too small cuff will give a falsely higher reading. The one-size-fits-all BP monitors are often too small for our rapidly "expanding" patient population.
One of my partners treated a patient who's presenting complaint was that he couldn't find a primary care physician (PCP). The patient has HTN and had been started on meds during a prior ER visit. His prescriptions had run out. The ER as primary care center is an issue the continues to grow in importance. When a patient checks their BP and gets a high reading they rush and call their PCP. The advice is usually to go to the ER for further evaluation.
HTN was once referred to as the silent killer. Because HTN causes no symptoms, the initial presentation could be when the end organ damage has occurred. Prolonged untreated HTN strains the heart. The left ventricle compensates for elevated systolic BP by getting thicker. Hypertrophy of the muscle of the left ventricle will eventually lead to heart failure or heart attack. The brain's autoregulatory ability will, over time, fail and stroke will be the result. The kidneys are involved in blood pressure regulation. These vitals organs will also be damaged by long standing HTN.
I know that this will sound familiar but here goes: Maintain a healthy weight. Exercise regularly. Limit your salt intake. See your PCP for regular check ups. Take your blood pressure meds as prescribed. HTN is a chronic but manageable disease. Do not stop taking your BP meds without getting your doctor's OK. Normal BP for an adult is based on recommendations from the American Heart Association. Visit their website for current advisories.
Saturday, July 3, 2010
July 4th
Happy Birthday USA. Summer is here. The forecast is for 90 + degree days for the next week. My elderly hound and I are home with the AC on, watching the World Cup. I got a little nervous when he began barking Deutcheland Uber Alles, during the morning match. The Argentine drama queens died like dogs in the second half.
Hot times in the ER lead to heat related illnesses. Heat exhaustion, sunburns, and heat stroke are all common presenting complaints during the summer. Our large elderly population is especially vulnerable to heat related conditions.
The human response to heat stress is very efficient. Vasodilitation brings increased blood flow to the skin. Sweat glands produce copious amounts of perspiration which cools us by evaporation. Respiratory rate also increases as we exhale warm air (think of a dog panting). Under most conditions and with adequate fluid replacement, humans handle heat very well. Unfortunately, lots of medical conditions, medications and social situations can lead to a failure of these compensatory mechanisms of heat dissipation.
Numerous medications, taken for many common illnesses, impair a patient's response to heat. Diuretics (water pills) tend to dehydrate the patient and may impair the kidney's ability to preserve water loss. Other blood pressure medications limit the heart rate and interfere with the shunting of blood to the skin. Many meds for depression, bipolar disorder, schizophrenia and common allergies, all impair sweating.
Medications such as doxycycline (a common antibiotic used to treat acne and other infections) can photo sensitise a patient. Someone taking these meds, who is exposed to the sun's rays may develop a painful and severe "sunburn" even when sunscreens are used. Not using sunscreens or not applying the sunblock correctly lead to sunburn. The pain of the sunburn also is accompanied by damage to the heat shedding ability of the skin. This increases the risk of heat exhaustion and heat stroke.
Lack of adequate fluid replacement is a major factor in heat illnesses. Immobility from neurological conditions, or diminished thirst from medications are especially common in the elderly. Seniors, who living alone die, every summer because of heat illnesses.
The initial symptoms of heat exhaustion may be subtle. The patient is still sweating and may only experience a vague feeling of being lightheaded. Healthy outdoor workers and athletes training in hot conditions make up many of the heat exhaustion victims. High humidity along with elevated ambient temperatures impede the cooling effect of sweating. As the body's core temperature rises, the patient becomes increasingly weak. Initial examination in the ER shows tachycardia, and hypotension. The skin is usually damp and cool to the touch. Mental function is intact early in heat exhaustion. The treatment is to get the patient out of the heat and sun. Give fluids (water is still best) and a fan may help promote evaporation.
Heat stroke is a true medical emergency. Rapid treatment is necessary to prevent damage to the brain, heart and kidneys. The patient is usually hot and dry. Mental impairment is very common. Core temperature is elevated. Readings of 103 degrees and above are the rule. Rapid cooling and rehydration are life saving. Methods of cooling vary with the extent and degree of hyperthermia. Ice packs, misting and fans, cooled IV fluids and even infusing of cooled fluids through tubes placed in the stomach, bladder and abdominal cavities may be employed. Close monitoring of cardiac rhythm, temperature, blood pressure, serum electrolytes and renal function are routine.
Even with treatment, a significant number of patient's with heat stroke will succumb to the damage occurring prior to arrival in the ER. Outdoor workers and athletes may develop rhabdomyolysis. This is destruction of muscle cells from heat stress, overuse and dehydration. The release of proteins from the damaged muscles block the filtration mechanism of the kidney and lead to renal failure.
Prevention is the best approach to heat illnesses. Avoid heavy work and exercise during high heat and humidity conditions. If you must work in the heat, protect your skin from excessive sun exposure and drink copious amounts of water. Passing urine that is adequate in amount and normal specific gravity (as a guide: the darker yellow the urine, the higher the specific gravity) may help in maintaining hydration. Look in on your elderly family members, friends and neighbors. Insure that they have air conditioning and/or fans. Encourage them to drink water regularly. Get help if you think that signs of heat exhaustion are present.
Have a safe summer. Be smart. Apply sunscreens at least 20 minutes before sun exposure and reapply frequently. Drink lots of water. Know the signs of heat illnesses and seek help as soon as possible.
Hot times in the ER lead to heat related illnesses. Heat exhaustion, sunburns, and heat stroke are all common presenting complaints during the summer. Our large elderly population is especially vulnerable to heat related conditions.
The human response to heat stress is very efficient. Vasodilitation brings increased blood flow to the skin. Sweat glands produce copious amounts of perspiration which cools us by evaporation. Respiratory rate also increases as we exhale warm air (think of a dog panting). Under most conditions and with adequate fluid replacement, humans handle heat very well. Unfortunately, lots of medical conditions, medications and social situations can lead to a failure of these compensatory mechanisms of heat dissipation.
Numerous medications, taken for many common illnesses, impair a patient's response to heat. Diuretics (water pills) tend to dehydrate the patient and may impair the kidney's ability to preserve water loss. Other blood pressure medications limit the heart rate and interfere with the shunting of blood to the skin. Many meds for depression, bipolar disorder, schizophrenia and common allergies, all impair sweating.
Medications such as doxycycline (a common antibiotic used to treat acne and other infections) can photo sensitise a patient. Someone taking these meds, who is exposed to the sun's rays may develop a painful and severe "sunburn" even when sunscreens are used. Not using sunscreens or not applying the sunblock correctly lead to sunburn. The pain of the sunburn also is accompanied by damage to the heat shedding ability of the skin. This increases the risk of heat exhaustion and heat stroke.
Lack of adequate fluid replacement is a major factor in heat illnesses. Immobility from neurological conditions, or diminished thirst from medications are especially common in the elderly. Seniors, who living alone die, every summer because of heat illnesses.
The initial symptoms of heat exhaustion may be subtle. The patient is still sweating and may only experience a vague feeling of being lightheaded. Healthy outdoor workers and athletes training in hot conditions make up many of the heat exhaustion victims. High humidity along with elevated ambient temperatures impede the cooling effect of sweating. As the body's core temperature rises, the patient becomes increasingly weak. Initial examination in the ER shows tachycardia, and hypotension. The skin is usually damp and cool to the touch. Mental function is intact early in heat exhaustion. The treatment is to get the patient out of the heat and sun. Give fluids (water is still best) and a fan may help promote evaporation.
Heat stroke is a true medical emergency. Rapid treatment is necessary to prevent damage to the brain, heart and kidneys. The patient is usually hot and dry. Mental impairment is very common. Core temperature is elevated. Readings of 103 degrees and above are the rule. Rapid cooling and rehydration are life saving. Methods of cooling vary with the extent and degree of hyperthermia. Ice packs, misting and fans, cooled IV fluids and even infusing of cooled fluids through tubes placed in the stomach, bladder and abdominal cavities may be employed. Close monitoring of cardiac rhythm, temperature, blood pressure, serum electrolytes and renal function are routine.
Even with treatment, a significant number of patient's with heat stroke will succumb to the damage occurring prior to arrival in the ER. Outdoor workers and athletes may develop rhabdomyolysis. This is destruction of muscle cells from heat stress, overuse and dehydration. The release of proteins from the damaged muscles block the filtration mechanism of the kidney and lead to renal failure.
Prevention is the best approach to heat illnesses. Avoid heavy work and exercise during high heat and humidity conditions. If you must work in the heat, protect your skin from excessive sun exposure and drink copious amounts of water. Passing urine that is adequate in amount and normal specific gravity (as a guide: the darker yellow the urine, the higher the specific gravity) may help in maintaining hydration. Look in on your elderly family members, friends and neighbors. Insure that they have air conditioning and/or fans. Encourage them to drink water regularly. Get help if you think that signs of heat exhaustion are present.
Have a safe summer. Be smart. Apply sunscreens at least 20 minutes before sun exposure and reapply frequently. Drink lots of water. Know the signs of heat illnesses and seek help as soon as possible.
Thursday, July 1, 2010
Fascinomas
Even after thirty years in the ER, the world's oldest ER doc still encounters rare and challenging diseases. A 30 year old Cambodian man with a foot drop clearly wasn't having a stroke. I found no evidence of trauma or metabolic disorders. A nodule lateral to his knee seemed suspicious. A biopsy of this nodule revealed the diagnosis, leprosy. The daughter of a nurse and close friend from the ER, had been in South America during one semester in college. On a trip home she showed me a sore on her foot. Treatment for a bacterial infection proved futile. The diagnosis was leishmaniasis, a parasitic disease spread by sand flea bites in endemic areas.
This week I went in to examine a woman in her seventies with a chief complaint of weakness and just not acting like "herself". Her family was helpful in giving me a sense of her usual health and the medications she takes were in a "bag-o-meds". She was weak, short of breath and her capillary sugar was 400 +. Lab tests showed severe metabolic acidosis. The pH of human blood is 7.4. This patient's pH was 6.67. One of my young partners commented that she should have been dead. She was able to follow instructions and even speak. Her medications included metformin. This is a commonly used medication for type II diabetes. It has an uncommon side effect of causing lactic acidosis. A lactic acid determination confirmed the diagnosis. The normal lactic acid level is < 2. A level of 5 is considered critical. My patient's level was 15. I began appropriate therapy and admitted her to the ICU. My friend Dr L, the intensivist was incredulous when I gave him her lab results. He also felt that she should not be among the living with a pH of 6.67. The patient rapidly improved.
Patients who suffer a cardiac arrest outside the hospital rarely survive. Unless bystander CPR is immediately initiated and advanced life support including entubation, continued CPR and specific medications given within 15 minutes, the patient's brain will suffer irreversible damage. A recent innovation is cooling the patient with cold IV solutions, and ice packs to slow the metabolism and try and preserve brain function. Patient as freeze pop. Sadly the outcome is rarely a full recovery.
A recent 62 year man was brought in to the ER after an unwitnessed cardiopulmomary arrest. His initial rythym on the monitor was asystole, no cardiac electrical activity. The ACLS protocol was begun and continued on route. A weak pulse was obtained, just as he cleared the outer ER doors. A contiunous IV drip of isoprel maintained a reasonable pulse and blood pressure. The chest x-ray showed fluid and a questionable mass in his right lung. The lab results showed a sodium of 118. The normal sodium (NA) is 140. This gentleman died 2 days later because of his anoxic brain injury. His brain was deprived of oxygen for too long.
The low sodium was a mystery but I had a theory. Many cancers, especially lung tumors secrete hormones. ADH (anti-diuretic hormone) is normally secreted during times of dehydration so that the kidneys with preserve water. SIADH (syndrome of inappropriate ADH) occurs when the hormone is produced in the normal water balance state. As water is retained, the sodium in the blood is slowly lowered. When the level gets too low, seizures and cardiac arrythymias may occur.
I arrived home that morning and my wife asked "how did the night go". My response was "no one died". Fascinomas keep me curious and focused. 30 years, 20-30 patients per shift, currently 12 shifts per month (formerly 16-18 shifts per month), you do the math. The challenge of unusual and rare diseases and injuries keep me on my toes and prevent my job from becoming routine. I will continue to post rare-anomas and fascinomas in future blogs.
This week I went in to examine a woman in her seventies with a chief complaint of weakness and just not acting like "herself". Her family was helpful in giving me a sense of her usual health and the medications she takes were in a "bag-o-meds". She was weak, short of breath and her capillary sugar was 400 +. Lab tests showed severe metabolic acidosis. The pH of human blood is 7.4. This patient's pH was 6.67. One of my young partners commented that she should have been dead. She was able to follow instructions and even speak. Her medications included metformin. This is a commonly used medication for type II diabetes. It has an uncommon side effect of causing lactic acidosis. A lactic acid determination confirmed the diagnosis. The normal lactic acid level is < 2. A level of 5 is considered critical. My patient's level was 15. I began appropriate therapy and admitted her to the ICU. My friend Dr L, the intensivist was incredulous when I gave him her lab results. He also felt that she should not be among the living with a pH of 6.67. The patient rapidly improved.
Patients who suffer a cardiac arrest outside the hospital rarely survive. Unless bystander CPR is immediately initiated and advanced life support including entubation, continued CPR and specific medications given within 15 minutes, the patient's brain will suffer irreversible damage. A recent innovation is cooling the patient with cold IV solutions, and ice packs to slow the metabolism and try and preserve brain function. Patient as freeze pop. Sadly the outcome is rarely a full recovery.
A recent 62 year man was brought in to the ER after an unwitnessed cardiopulmomary arrest. His initial rythym on the monitor was asystole, no cardiac electrical activity. The ACLS protocol was begun and continued on route. A weak pulse was obtained, just as he cleared the outer ER doors. A contiunous IV drip of isoprel maintained a reasonable pulse and blood pressure. The chest x-ray showed fluid and a questionable mass in his right lung. The lab results showed a sodium of 118. The normal sodium (NA) is 140. This gentleman died 2 days later because of his anoxic brain injury. His brain was deprived of oxygen for too long.
The low sodium was a mystery but I had a theory. Many cancers, especially lung tumors secrete hormones. ADH (anti-diuretic hormone) is normally secreted during times of dehydration so that the kidneys with preserve water. SIADH (syndrome of inappropriate ADH) occurs when the hormone is produced in the normal water balance state. As water is retained, the sodium in the blood is slowly lowered. When the level gets too low, seizures and cardiac arrythymias may occur.
I arrived home that morning and my wife asked "how did the night go". My response was "no one died". Fascinomas keep me curious and focused. 30 years, 20-30 patients per shift, currently 12 shifts per month (formerly 16-18 shifts per month), you do the math. The challenge of unusual and rare diseases and injuries keep me on my toes and prevent my job from becoming routine. I will continue to post rare-anomas and fascinomas in future blogs.
Subscribe to:
Posts (Atom)