Yes, it's time to send our children back to school. Eager minds have pined all summer, thirsting for knowledge. My younger nephews and godson are all heading to their classrooms. I spent more than $600 yesterday on my nephews for clothes, shoes, and supplies. My nephew in college, who will be turning 21 this semester, got some free advise as to dangers of excessive drinking. I think he was listening.
A recent tragedy spurred me to blogify about the perils and ER related aspects of the return to school next week. A high school star athlete was killed in a single car crash. He probably would have survived, if he had been wearing his seatbelt. Inexperienced drivers, feelings of invincibility, cell phones and friends in the vehicle are the ingredients for the all too frequent MVC's involving young drivers as they head back to school.
A word about neuroanatomy may be illuminating. The frontal lobes of the brain are important in both complex motor function and in judgement. The frontal cortex is slow to develop, and isn't fully mature until the mid to late twenties. Combine lack of judgment, excess testosterone/estrogen, and distractions from MP3 players, and cell phones and you have a recipe for an ER trauma patient.
The city where I practice the art of EM is home to a large state university. Every year, as the freshmen arrive, the first case of alcohol poisoning appears. I dread that call to the parents, telling them that Johnny or Susie is entubated and on a ventilator with acute ethanol poisoning. Deaths from alcohol and drugs such as Ecstasy, methamphetamines occur in college and high school students. Prescription drugs are also frequently abused. Ritalin, Provigil and other stimulants are used to help cram for exams and just to get buzzed. These medications can cause potentially dangerous heart rhythm problems.
Sedatives such as Rohypnol and alcohol may be used to commit sexual assaults. Both women and men have been raped while under the influence of sedatives. The assailants may be law abiding citizens, who commit their crimes while they too are impaired by alcohol and/or drugs. Lives are permanently damaged.
I would encourage my younger readers to review "Sex in the ER" parts 1 and 2. Freshmen in college are often experiencing independence from their parents for the first time. The intimacy of dormitory living and the excitement of college life get the hormones churning. An 18 year old coed who finds out from Robin, my PA, that she has Herpes, realizes too late that she should have practiced safe sex. Herpes and HIV are treatable but not curable. A single unprotected encounter may last a lifetime.
Parents, other family members and friends of all students, please do your best to prepare your children. School is not a punishment. Children must grow and develop to eventually become independent adults. Helicoptering is not a good solution to the anxiety of being a parent. SAT prep courses, e-mailing teachers to protest grades, and doing your children's assignment will fail in the long run. Grade inflation and trophies for trying frustrate the value of learning from one's mistakes.
Talk to your children openly and honestly about the joy of learning. Don't neglect to discuss drugs, alcohol and sex. A parent is still the most important teacher that a child will have in their life. Fell free to invite your children to read and comment on this blog.
Friday, August 27, 2010
Sunday, August 22, 2010
Spare parts
The bionic man is still just a bad TV series, but more patients than ever have pieces of metal and plastic and even sophisticated electronics inside their bodies. Joints, stents, ports, lines, pacers, defibrillators, shunts and implants are all "foreign bodies". If bacteria get into the blood stream, these foreign bodies can become infected and the resulting fever and chills will send the patient to the ER.
Bacteremia can occur from dental procedures, catheterizations, and from on-going infections of the skin that get into the deeper tissue. Using needles to inject drugs is an obvious source of infective organisms entering the blood stream. Many dangerous bacterial species produce a biofilm on the surface of the spare parts. This film protects the microorganism from the antibiotics used to treat the infections.
PICC lines and Portacaths are ways of having intermittent and prolonged access to the venous system. Cancer patients, and patients needing prolonged nutritional or antibiotic treatment have these devices.
Hips, knees, elbows, shoulders and other joints can all be replaced when they become damaged from injury or disease. The artificial joints are made from non-ferrous metal and plastic. They can become infected as mentioned earlier. These joints, especially prosthetic hips are prone to dislocation. ER docs are often asked to reduce a dislocated hip after a fall or movement that "pops" the joint out. Conscious sedation is used to get adequate relaxation of the muscles during an attempt at reducing the dislocation.
Vascular, biliary, and ureteral stents are used to prop open channels. The current best treatment for most myocardial infarctions (heart attacks) is immediate cardiac catheterization and placement of a stent to open a blocked coronary artery. Vascular stents are also used in the carotid arteries in the neck and throughout the arterial circulation. Stents may be placed by a gastroenterologist into the bile duct if scarring or tumors are blocking this structure. Pancreatic cancer may invade or compress the flow of bile which would cause the patient to become jaundiced.
Renal stones cause horrific pain as they pass from the kidney to the bladder, by way of the ureter. Small stones may pass spontaneously. Larger stones may require procedures to break the stone into small pieces, that can be passed. A ureteral stent may be passed up from the bladder, using a cystoscope, to allow urine to flow around the stone until a lithotripsy or other procedure is performed.
Shunts are used by neurosurgeons to remove cerebrospinal fluid from the ventricles of the brain and empty into the abdominal cavity. These VP (ventricle-peritoneal) shunts are palpable as a button-like reservoir on the surface of the skull and a tube tunneled under the skin to the abdomen. The one-way valve of the shunt can malfunction causing increased intracranial pressure. The patient may present to the ER with headache, nausea and vomiting. A VP shunt may also get infected.
Pacemakers and implantable defibrillators are complex electronic devices used to keep a heart beating or to shock a fibrillating heart back to a stable rhythm. They are programmable and give information of their activities to the cardiologist. Mechanical problems include twisting in the "pocket" of skin in which the devise resides. Wires and leads may fracture. The battery will eventually need replacing but can fail unexpectedly. A defibrillator may oversense and send shocks to the patient when there is no fibrillation. A run-away pacer may accelerate the heart rate to dangerous levels. As with all spare parts, they may become infected.
A form of pacemaker is being used in patients with certain types of seizures and even in patients with intractable pain. These devices give electrical impulses to nerves or the spinal cord. These pacers are prone to all the problems associated with cardiac pacemakers. A cochlear implant is a device used to give hearing to patients with the most common form of deafness. The ER doc must be able to recognize and begin treatment if these devises become infected.
I would be remiss if I didn't mention the use of implants in cosmetic surgery. Breast implants are plastic bags filled with saline, oil or silicone. Similar implants are also being used to enhance a man's pectoral muscles and to augment the buttocks of both men and women. The face may be a repository of material in the cheeks and chin during cosmetic procedures. Rupturing of the implant, shifting of its position and the ever present risk of infection may bring the patient to the ER doors. Dentist implants are usually dealt with by our colleagues in the dental sciences.
The transplantation of organs is a future topic for your scribe.
Bacteremia can occur from dental procedures, catheterizations, and from on-going infections of the skin that get into the deeper tissue. Using needles to inject drugs is an obvious source of infective organisms entering the blood stream. Many dangerous bacterial species produce a biofilm on the surface of the spare parts. This film protects the microorganism from the antibiotics used to treat the infections.
PICC lines and Portacaths are ways of having intermittent and prolonged access to the venous system. Cancer patients, and patients needing prolonged nutritional or antibiotic treatment have these devices.
Hips, knees, elbows, shoulders and other joints can all be replaced when they become damaged from injury or disease. The artificial joints are made from non-ferrous metal and plastic. They can become infected as mentioned earlier. These joints, especially prosthetic hips are prone to dislocation. ER docs are often asked to reduce a dislocated hip after a fall or movement that "pops" the joint out. Conscious sedation is used to get adequate relaxation of the muscles during an attempt at reducing the dislocation.
Vascular, biliary, and ureteral stents are used to prop open channels. The current best treatment for most myocardial infarctions (heart attacks) is immediate cardiac catheterization and placement of a stent to open a blocked coronary artery. Vascular stents are also used in the carotid arteries in the neck and throughout the arterial circulation. Stents may be placed by a gastroenterologist into the bile duct if scarring or tumors are blocking this structure. Pancreatic cancer may invade or compress the flow of bile which would cause the patient to become jaundiced.
Renal stones cause horrific pain as they pass from the kidney to the bladder, by way of the ureter. Small stones may pass spontaneously. Larger stones may require procedures to break the stone into small pieces, that can be passed. A ureteral stent may be passed up from the bladder, using a cystoscope, to allow urine to flow around the stone until a lithotripsy or other procedure is performed.
Shunts are used by neurosurgeons to remove cerebrospinal fluid from the ventricles of the brain and empty into the abdominal cavity. These VP (ventricle-peritoneal) shunts are palpable as a button-like reservoir on the surface of the skull and a tube tunneled under the skin to the abdomen. The one-way valve of the shunt can malfunction causing increased intracranial pressure. The patient may present to the ER with headache, nausea and vomiting. A VP shunt may also get infected.
Pacemakers and implantable defibrillators are complex electronic devices used to keep a heart beating or to shock a fibrillating heart back to a stable rhythm. They are programmable and give information of their activities to the cardiologist. Mechanical problems include twisting in the "pocket" of skin in which the devise resides. Wires and leads may fracture. The battery will eventually need replacing but can fail unexpectedly. A defibrillator may oversense and send shocks to the patient when there is no fibrillation. A run-away pacer may accelerate the heart rate to dangerous levels. As with all spare parts, they may become infected.
A form of pacemaker is being used in patients with certain types of seizures and even in patients with intractable pain. These devices give electrical impulses to nerves or the spinal cord. These pacers are prone to all the problems associated with cardiac pacemakers. A cochlear implant is a device used to give hearing to patients with the most common form of deafness. The ER doc must be able to recognize and begin treatment if these devises become infected.
I would be remiss if I didn't mention the use of implants in cosmetic surgery. Breast implants are plastic bags filled with saline, oil or silicone. Similar implants are also being used to enhance a man's pectoral muscles and to augment the buttocks of both men and women. The face may be a repository of material in the cheeks and chin during cosmetic procedures. Rupturing of the implant, shifting of its position and the ever present risk of infection may bring the patient to the ER doors. Dentist implants are usually dealt with by our colleagues in the dental sciences.
The transplantation of organs is a future topic for your scribe.
Sunday, August 15, 2010
Young at heart
Recently I examined a teenaged boy with fever, muscles aches, headaches and intermittent vomiting. There were no signs of meningitis, no respiratory complaints but persistent high fevers despite acetaminophen and ibuprofen. The labs tests were not helpful. I sent a sample of blood for testing for Lyme disease and started amoxicillin for presumed Lyme disease. In much of the New England, Lyme disease has become prevalent.
Fast forward 2 days, and this polite and well spoken young man is back in the ER with his mother. A non-productive cough and significant shortness of breath have developed. One of my partners has examined the patient and we meet at the x-ray screen. The chest x-ray shows an enlarged heart and signs of congestive heart failure. My partner performs an ultrasound of the heart showing poor motion of the heart muscle and fluid around the heart in the pericardial sac.
The patient was tranferred to a pediatric CCU in a major teaching hospital. The presumptive diagnosis was myocarditis. Inflammation of the myocardium can be caused by infection, toxins and immunological disorders. Viruses especially coxsackie B and echovirus are the most common infectious agents. Parasites, protozoans, bacteria and fungi may also cause myocarditis.
Toxins that cause myocarditis include clozapine, an atypical antipsychotic used to treat schizophrenia. Cocaine is a direct myocardial toxin as well as a vasoconstrictor that can precipitate an MI (heart attack). A number of immunological disease such as sardcoidosis, rheumatoid arthritis and lupus cause myocarditis.
Chest pain in young patients rarely occurs from coronary artery disease. Kawasaki disease is a complex condition that may include injury to the coronary arteries in children. Pericarditis, inflammation of the membranes that cover the and enclose the heart, also presents with chest pain in young people. The etiology of pericarditis includes infections, medications, immunological and metabolic disorders.
The title of this blog relates to the fact that this patient was, is and will remain in my "heart". Doctors enjoy discussing unusual and challenging patients and diseases. This patient definitely falls into the category of a "great case". I try to connect with all of patients. Having been at the same hospital for most of my career, it is common for me to see patients and/or their family members more than once. Each shift I seek out "the one". A patient who breaks through the 30 years of EM cases and touches my cynical soul. This was the first time that I met this patient and his mother. He and I spoke about entering high school in September. We reside in the same town. He was "the one".
Emergency medicine is all about the moment. ER staff rarely gets follow up information concerning patients who are tranferred to other hospitals. The immediacy of EM has always been a great part of my career choice. The lack of follow up is a source of frustration. I will hope for a good outcome for this young man.
Another week begins. Another 20-30 patients to be examined and treated per shift. Another search for "the one".
Fast forward 2 days, and this polite and well spoken young man is back in the ER with his mother. A non-productive cough and significant shortness of breath have developed. One of my partners has examined the patient and we meet at the x-ray screen. The chest x-ray shows an enlarged heart and signs of congestive heart failure. My partner performs an ultrasound of the heart showing poor motion of the heart muscle and fluid around the heart in the pericardial sac.
The patient was tranferred to a pediatric CCU in a major teaching hospital. The presumptive diagnosis was myocarditis. Inflammation of the myocardium can be caused by infection, toxins and immunological disorders. Viruses especially coxsackie B and echovirus are the most common infectious agents. Parasites, protozoans, bacteria and fungi may also cause myocarditis.
Toxins that cause myocarditis include clozapine, an atypical antipsychotic used to treat schizophrenia. Cocaine is a direct myocardial toxin as well as a vasoconstrictor that can precipitate an MI (heart attack). A number of immunological disease such as sardcoidosis, rheumatoid arthritis and lupus cause myocarditis.
Chest pain in young patients rarely occurs from coronary artery disease. Kawasaki disease is a complex condition that may include injury to the coronary arteries in children. Pericarditis, inflammation of the membranes that cover the and enclose the heart, also presents with chest pain in young people. The etiology of pericarditis includes infections, medications, immunological and metabolic disorders.
The title of this blog relates to the fact that this patient was, is and will remain in my "heart". Doctors enjoy discussing unusual and challenging patients and diseases. This patient definitely falls into the category of a "great case". I try to connect with all of patients. Having been at the same hospital for most of my career, it is common for me to see patients and/or their family members more than once. Each shift I seek out "the one". A patient who breaks through the 30 years of EM cases and touches my cynical soul. This was the first time that I met this patient and his mother. He and I spoke about entering high school in September. We reside in the same town. He was "the one".
Emergency medicine is all about the moment. ER staff rarely gets follow up information concerning patients who are tranferred to other hospitals. The immediacy of EM has always been a great part of my career choice. The lack of follow up is a source of frustration. I will hope for a good outcome for this young man.
Another week begins. Another 20-30 patients to be examined and treated per shift. Another search for "the one".
Saturday, August 7, 2010
Proust
The title refers to "Remembrance of Things Past". I got a phone message this morning from a woman who I first met in nursery school in 1956. The 40th reunion of the high school that I attended during 10th grade is coming up this fall. I left this school and graduated from a private school. There were 2 reasons for my choice. I wanted a more academically challenging education and I was a nerd/geek. My interests included history, mathematics and science. Being tall and skinny, and very average in the looks department sealed my status. My few friends were the other brains and dweebs at the public high school. The private school I attended was a male only bastion of the WASP elite. My interests were nurtured and I received a first rate education.
Reunions of any kind hold little appeal for me. I have attended my wife's 25th college reunion and the 25th high school reunion of the school that drove me out. A dear friend who graduated from Hometown High wanted to experience reunion(ing) with the very people who ostracized us. My friend's husband had zero desire to attend, so I went as her date.
The same "girls" who barely acknowledged my existence as a teen, now seemed enamored to be reacquainted. Being an MD, driving a $40,000 car, wearing an Italian made suit, and sporting a Rolex watch (a gift from my beautiful wife) made me attractive.
The experience of this reunion strengthened my philosophy of never going backwards. Trying to maintain the ties of one's youth will not keep you young. Embracing the present and anticipating the challenges of the future are the key to a vibrant life. Study the past, but don't live in the past.
Medical knowledge is ever expanding. To remain effective as a physician requires a great deal of time and effort. The history of medicine is a particular interest of mine. The pioneers of modern medicine laid the foundation that is still relevant today. The eponymous diseases such as Crohn's, Parkinson's, and Huntington's are windows into our heritage as physicians.
Being the senior attending in my ER group is a never ending source of stimulation. Bright, eager ER docs, fresh from their residencies join our practice. The ways of the force are mysterious. Much to learn, do they have. Yoda am I. These young ER docs encourage me to keep up with the latest information and tools of Emergency Medicine.
This year we welcomed a new doctor. He completed his Emergency Medicine residency just weeks before joining our group. He is smart, articulate, compassionate and hard working. He also is so young, that he had not been born when I was the new ER doc, fresh from my residency, 30 years ago. I was excited to learn that he is a second generation ER doc as his mother is also a member of our guild.
No reunion for the world's oldest ER doc. I would rather hang with my current posse, than reminisce with the spectres of my past.
Reunions of any kind hold little appeal for me. I have attended my wife's 25th college reunion and the 25th high school reunion of the school that drove me out. A dear friend who graduated from Hometown High wanted to experience reunion(ing) with the very people who ostracized us. My friend's husband had zero desire to attend, so I went as her date.
The same "girls" who barely acknowledged my existence as a teen, now seemed enamored to be reacquainted. Being an MD, driving a $40,000 car, wearing an Italian made suit, and sporting a Rolex watch (a gift from my beautiful wife) made me attractive.
The experience of this reunion strengthened my philosophy of never going backwards. Trying to maintain the ties of one's youth will not keep you young. Embracing the present and anticipating the challenges of the future are the key to a vibrant life. Study the past, but don't live in the past.
Medical knowledge is ever expanding. To remain effective as a physician requires a great deal of time and effort. The history of medicine is a particular interest of mine. The pioneers of modern medicine laid the foundation that is still relevant today. The eponymous diseases such as Crohn's, Parkinson's, and Huntington's are windows into our heritage as physicians.
Being the senior attending in my ER group is a never ending source of stimulation. Bright, eager ER docs, fresh from their residencies join our practice. The ways of the force are mysterious. Much to learn, do they have. Yoda am I. These young ER docs encourage me to keep up with the latest information and tools of Emergency Medicine.
This year we welcomed a new doctor. He completed his Emergency Medicine residency just weeks before joining our group. He is smart, articulate, compassionate and hard working. He also is so young, that he had not been born when I was the new ER doc, fresh from my residency, 30 years ago. I was excited to learn that he is a second generation ER doc as his mother is also a member of our guild.
No reunion for the world's oldest ER doc. I would rather hang with my current posse, than reminisce with the spectres of my past.
Friday, August 6, 2010
OD
Sobering statistics about suicide rates were reported in an EM journal yesterday. Unless the victim is found dead, suicide attempts end up in the ER. The biochemistry of depression has been established. Levels of neurotransmitters in sections of the brain are the biological basis of depression. We all get the blues. I am listening to "the Blues" as I write this blog. Clinical depression is unremitting sadness. The depressed patient feels no joy. Sleep, appetite, energy levels are all affected. Hopelessness leads to suicidal thoughts and suicide attempts. The young and the elderly are most likely to attempt suicide. The elderly and all males are most likely to succeed. Violent means of suicide (guns, hanging, jumping from height, car crashes) are more often the choice of men. Pills and non-medication ingestions are the preferred means for women.
Almost any medication in the family medicine cabinet can be lethal in high enough doses. Acetaminophen (Tylenol and others), ibuprofen (Advil etc.) and aspirin are all lethal in high doses. Sleep aides, cold pills and allergy meds can kill. Household cleaners and plumbing supplies are especially dangerous. Rubbing alcohol and antifreeze will do the trick. Prescription medications of all types may kill if taken in excessive quantities.
The Hemlock Society offers suicide "how-to" information. The internet has a wealth of insight into the most lethal medications and toxins. Fortunately, the ER staff has the same access to the treatments and antidotes for ingestions used in suicide attempts. The key is the history: what was taken, how much was swallowed, and when did the ingestion occur. Toxidromes are the signs and symptoms in the patient who has ingested certain medications or plants. The ER doc can make educated assumptions as to the type of drug ingested by the appearance, vital signs, and physical examination of the patient.
Lots of mnemonics have been created to aid the ER staff in remembering these toxidromes. Antihistamines such as Benadryl, if taken in large amounts, may present as a patient who is "red as a beet, dry as a bone, hot as a hen, and mad as a hatter". A little historical aside: the phrase, "mad as a hatter" refers to the fact that hat makers, in the past, used chemicals containing mercury to work the felt. The exposure to mercury caused damage to their brains; they became "mad".
I read a new mnemonic recently, METAL ACID GAP. This is to help in recalling the causes of high anion gap metabolic acidosis (HAGMA). Earlier this week an ambulance arrived with a 60ish patient. The call said he was having a stroke. The patient was comatose but moved both arms when I rubbed my knuckles over his sternum. Scraping a tongue depressor on the soles of his feet showed a normal Babinski response. He was breathing at more than 30 respirations per minute. This was not a stroke. Labs tests showed a profound metabolic acidosis. His pH was 7.07 (normal 7.4), his bicarb was 8 and his carbon dioxide level was 11. His anion gap was greater than 100. The anion gap is the difference between the calculated osmoles in the serum of the blood such as sodium, glucose, BUN, etc and the direct measurement of the osmolality of the serum. The gap leads to a search for the "missing osmole". The patient's family was most helpful. When I described the types of medications and household products that could cause his condition, they found what I had suspected. The patient had ingested antifreeze which contains ethylene glycol. This chemical is fatal in even small ingestions. A treatment does exist for this toxin. If begun soon after the ingestion, the patient should survive.
Acetaminophen, ibuprofen, aspirin and diphenhydramine (Benadryl) are the most frequently used non-prescriptions medications in suicide attempts. Acetaminophen is particularly nasty. As few as 30 regular strength tablets are enough to cause liver injury and possibly death from liver failure, in a small teen or adult. A very effective antidote exists, but if the treatment is started too long after the ingestion, the liver damage may be irreversible. The kidneys are frequently injured by toxic ingestions of OTC (over the counter/ non-prescription) pain medications. Hemodialyis is used to both treat the renal failure caused by the ingestion and to remove the toxin from the blood.
Vitamins, mineral supplements, and herbal medication may also cause injury and death in large ingestions. Iron compounds are a cause of HAGMA. The tendency of iron tablets and certain other pills to form concretions makes the ER doc's job more difficult. One of the most important parts of treating OD's is to prevent further absorption of the toxin from the GI tract. A concretion is a hard lump of tablets. Activated charcoal is given orally to overdose victims in an effort to bind the offending drug and carry it out the rectum. Minerals do not bind to charcoal and concretions of meds such as aspirin, prevent the charcoal from fully binding the drug. The resourceful ER staff, after entubating the patient to protect the airway, will use whole bowel irrigation to try and flush the pills out of the gut. A large tube is passed down the esophagous to the stomach, and liters of solution are infused until the results from the rectum are running clear.
A word about physician assisted suicide is in order. Patients with chronic medical conditions, that will lead to incapacitation, or those patients having intractable pain, may wish to end their lives. Some countries allow the physicians caring for these patients to prescribe medications to aide the patient in ending his or her life. The medications prescribed are usually potent sedatives. In high enough doses, these drugs will depress respirations, leading to fatal hypoxia and a rather peaceful death. Having witnessed my father's death I am strong supporter of physician assisted suicide. Terminal cancer patients in hospice care are given lorazepam, morphine, fentanyl, etc. While the doses are not directly lethal, they ease the patient's death. If I was faced with a painful or undignified demise, I would want to have the option of dying at a time of my choice. A bottle of 30 year old single malt scotch and a sufficient quantity of tricyclic antidepressants would be my personal formula.
Overdoses are frequent, unpredictable and always challenge the ER staff. The patient often does not wish to be treated. After all, they took the overdose to get high or to die. Having to use physical restraints, and placing tubes in every body orifice, would be considered assault and battery in any other locale. The ER staff makes every effort to preserve life. It was a good week for me, none of my patients died.
Almost any medication in the family medicine cabinet can be lethal in high enough doses. Acetaminophen (Tylenol and others), ibuprofen (Advil etc.) and aspirin are all lethal in high doses. Sleep aides, cold pills and allergy meds can kill. Household cleaners and plumbing supplies are especially dangerous. Rubbing alcohol and antifreeze will do the trick. Prescription medications of all types may kill if taken in excessive quantities.
The Hemlock Society offers suicide "how-to" information. The internet has a wealth of insight into the most lethal medications and toxins. Fortunately, the ER staff has the same access to the treatments and antidotes for ingestions used in suicide attempts. The key is the history: what was taken, how much was swallowed, and when did the ingestion occur. Toxidromes are the signs and symptoms in the patient who has ingested certain medications or plants. The ER doc can make educated assumptions as to the type of drug ingested by the appearance, vital signs, and physical examination of the patient.
Lots of mnemonics have been created to aid the ER staff in remembering these toxidromes. Antihistamines such as Benadryl, if taken in large amounts, may present as a patient who is "red as a beet, dry as a bone, hot as a hen, and mad as a hatter". A little historical aside: the phrase, "mad as a hatter" refers to the fact that hat makers, in the past, used chemicals containing mercury to work the felt. The exposure to mercury caused damage to their brains; they became "mad".
I read a new mnemonic recently, METAL ACID GAP. This is to help in recalling the causes of high anion gap metabolic acidosis (HAGMA). Earlier this week an ambulance arrived with a 60ish patient. The call said he was having a stroke. The patient was comatose but moved both arms when I rubbed my knuckles over his sternum. Scraping a tongue depressor on the soles of his feet showed a normal Babinski response. He was breathing at more than 30 respirations per minute. This was not a stroke. Labs tests showed a profound metabolic acidosis. His pH was 7.07 (normal 7.4), his bicarb was 8 and his carbon dioxide level was 11. His anion gap was greater than 100. The anion gap is the difference between the calculated osmoles in the serum of the blood such as sodium, glucose, BUN, etc and the direct measurement of the osmolality of the serum. The gap leads to a search for the "missing osmole". The patient's family was most helpful. When I described the types of medications and household products that could cause his condition, they found what I had suspected. The patient had ingested antifreeze which contains ethylene glycol. This chemical is fatal in even small ingestions. A treatment does exist for this toxin. If begun soon after the ingestion, the patient should survive.
Acetaminophen, ibuprofen, aspirin and diphenhydramine (Benadryl) are the most frequently used non-prescriptions medications in suicide attempts. Acetaminophen is particularly nasty. As few as 30 regular strength tablets are enough to cause liver injury and possibly death from liver failure, in a small teen or adult. A very effective antidote exists, but if the treatment is started too long after the ingestion, the liver damage may be irreversible. The kidneys are frequently injured by toxic ingestions of OTC (over the counter/ non-prescription) pain medications. Hemodialyis is used to both treat the renal failure caused by the ingestion and to remove the toxin from the blood.
Vitamins, mineral supplements, and herbal medication may also cause injury and death in large ingestions. Iron compounds are a cause of HAGMA. The tendency of iron tablets and certain other pills to form concretions makes the ER doc's job more difficult. One of the most important parts of treating OD's is to prevent further absorption of the toxin from the GI tract. A concretion is a hard lump of tablets. Activated charcoal is given orally to overdose victims in an effort to bind the offending drug and carry it out the rectum. Minerals do not bind to charcoal and concretions of meds such as aspirin, prevent the charcoal from fully binding the drug. The resourceful ER staff, after entubating the patient to protect the airway, will use whole bowel irrigation to try and flush the pills out of the gut. A large tube is passed down the esophagous to the stomach, and liters of solution are infused until the results from the rectum are running clear.
A word about physician assisted suicide is in order. Patients with chronic medical conditions, that will lead to incapacitation, or those patients having intractable pain, may wish to end their lives. Some countries allow the physicians caring for these patients to prescribe medications to aide the patient in ending his or her life. The medications prescribed are usually potent sedatives. In high enough doses, these drugs will depress respirations, leading to fatal hypoxia and a rather peaceful death. Having witnessed my father's death I am strong supporter of physician assisted suicide. Terminal cancer patients in hospice care are given lorazepam, morphine, fentanyl, etc. While the doses are not directly lethal, they ease the patient's death. If I was faced with a painful or undignified demise, I would want to have the option of dying at a time of my choice. A bottle of 30 year old single malt scotch and a sufficient quantity of tricyclic antidepressants would be my personal formula.
Overdoses are frequent, unpredictable and always challenge the ER staff. The patient often does not wish to be treated. After all, they took the overdose to get high or to die. Having to use physical restraints, and placing tubes in every body orifice, would be considered assault and battery in any other locale. The ER staff makes every effort to preserve life. It was a good week for me, none of my patients died.
Sunday, August 1, 2010
This is Spinal Tap
Lumbar puncture (LP) , what lay people call a spinal tap, is a diagnostic test performed by ER docs rather frequently. The procedure is done to determine two potentially life threatening medical conditions: infections of the brain or the coverings of the brain which are called encephalitis and meningitis respectively, and subarachnoid hemorrhage (SAH), blood leaking from blood vessels on the surface on the brain. Headaches, fever, vomiting, confusion and lethargy may all be symptoms on these diseases.
Meningitis is an inflammation of the three membranes that cover the brain and spinal cord. Viruses, bacteria and occasional fungi and parasites may cause these infections. Non-infectious causes of meningitis include certain cancers. Encephalitis is an infection of the brain most commonly caused by viruses. West Nile, Eastern Equine and Herpes Simplex viruses are the most likely etiological agents.
Subarachnoid bleeding usually arises from arteriovenous malformation (AVM) or aneurysms in the circle of Willis. A SAH is suspected in any patient who presents to the ER with the "worst headache of their life". Thunderclap headaches come on suddenly, with severe pain at the onset of the headache. Even people with chronic headaches, such as migraines, who report that their presenting headache is different and more severe than usual, may have a SAH.
CT scans of the brain are done on any patient suspected of having a SAH. A scan may also be carried out on a patient who may have meningitis or encephalitis, if the physician thinks there may be a mass and/or increased pressure in the brain. Blood from a SAH shows up well on a CT. About 1% of SAH will not be visible on an initial CT. If the patient comes in days after their thunderclap headache, the CT may be normal as the density of the SAH may make it invisible on the CT. An LP will be done to insure that no case of SAH is missed.
This past month I did three LP's. The three patients ranged in age from 10 days to 30 years. The infant presented with a significant fever. All neonates (less than a month old) who have fever above a certain threshold must have an LP to check for meningitis. The other two LP's were on an adolescent with fever, headache, vomiting and neck stiffness (the classic symptoms of meningitis), and a patient with sudden onset of the worst headache of one's life with a CT that was negative for blood.
An LP may be performed with the patient sitting up and bending forward. More commonly the patient lies on his or her side, and curls into the fetal position. The skin is carefully cleansed with an antibiotic solution. The area is draped with sterile barriers and the ER doc wears sterile gloves and a mask. In my early days as an ER doc, the only way to ameliorate this painful test was with local anesthesia to numb the area. Luckily for my patients and for me, conscious sedation is now readily available. During the LP, a spinal needle enters the skin in the midline of the lower back. The target is between the 4th and 5th or 3rd and 4th lumbar vertebrae. The location of the LP is to prevent damage to the spinal cord. Having the patient bending forward or curled forward makes it easier to pass the spinal needle between the vertebrae. The needle is advanced until a faint "pop" is felt. The needle has now pierced the dura, the tough outermost covering of the central nervous system. The stylet in the spinal needle is removed and cerebral spinal fluid (CSF) begins to flow.
A manometer is sometimes attached to the spinal needle to measure the pressure of the CSF. 3-4 tubes of fluid are obtained, each containing about 1 milliliter of CSF. The pressure, color, and clarity of the CSF may all give clues as to the diagnosis. The CSF is sent to the lab to be analyzed for the presence and number of both red (RBC) and white (WBC) blood cells. The number of WBC's are further divided into the type of WBC. If a SAH is suspected, the RBC count is performed on the 1st and 4th tubes to see if the number is the same or changing. The CSF is cultured for microorganisms, and examined under a microscope after being stained with dyes. The glucose and protein of the CSF is measured. Additional tests may be ordered if unusual infections are suspected.
I now offer all my patients the option of having their LP done with conscious sedation (CS). The agreeable patient (written informed consent) is placed on continuous monitoring of their heart rate, oxygen saturation and blood pressure. The drugs used vary, but all sedate the patient while maintaining spontaneous respirations. The ideal agent would have no effect of heart and lung function and wear off rapidly after the procedure is complete. CS is used in the ER for reduction of fractures and dislocation as well as LP. My personal preferred drug is Propofol. Despite the fact that this drug contributed to the death of Michael Jackson, it is safe and effective when used appropriately. In infants and young children, Ketamine may be used as an alternative to propofol.
Obese patients present a challenge in performing an LP and having conscious sedation. Ultrasound may aid the ER doc to find the anatomic guideposts that are hidden under adipose tissue. Severely obese patients are more likely to have respiratory compromise from CS because of the restriction of their body weight on their chest muscles and diaphragm.
In the northeast, where I work, summer is encephalitis season. Meningitis and SAH can occur at any time. The ER staff is ready and able to properly diagnose and treat patients with the headache that may be the BIG ONE.
Meningitis is an inflammation of the three membranes that cover the brain and spinal cord. Viruses, bacteria and occasional fungi and parasites may cause these infections. Non-infectious causes of meningitis include certain cancers. Encephalitis is an infection of the brain most commonly caused by viruses. West Nile, Eastern Equine and Herpes Simplex viruses are the most likely etiological agents.
Subarachnoid bleeding usually arises from arteriovenous malformation (AVM) or aneurysms in the circle of Willis. A SAH is suspected in any patient who presents to the ER with the "worst headache of their life". Thunderclap headaches come on suddenly, with severe pain at the onset of the headache. Even people with chronic headaches, such as migraines, who report that their presenting headache is different and more severe than usual, may have a SAH.
CT scans of the brain are done on any patient suspected of having a SAH. A scan may also be carried out on a patient who may have meningitis or encephalitis, if the physician thinks there may be a mass and/or increased pressure in the brain. Blood from a SAH shows up well on a CT. About 1% of SAH will not be visible on an initial CT. If the patient comes in days after their thunderclap headache, the CT may be normal as the density of the SAH may make it invisible on the CT. An LP will be done to insure that no case of SAH is missed.
This past month I did three LP's. The three patients ranged in age from 10 days to 30 years. The infant presented with a significant fever. All neonates (less than a month old) who have fever above a certain threshold must have an LP to check for meningitis. The other two LP's were on an adolescent with fever, headache, vomiting and neck stiffness (the classic symptoms of meningitis), and a patient with sudden onset of the worst headache of one's life with a CT that was negative for blood.
An LP may be performed with the patient sitting up and bending forward. More commonly the patient lies on his or her side, and curls into the fetal position. The skin is carefully cleansed with an antibiotic solution. The area is draped with sterile barriers and the ER doc wears sterile gloves and a mask. In my early days as an ER doc, the only way to ameliorate this painful test was with local anesthesia to numb the area. Luckily for my patients and for me, conscious sedation is now readily available. During the LP, a spinal needle enters the skin in the midline of the lower back. The target is between the 4th and 5th or 3rd and 4th lumbar vertebrae. The location of the LP is to prevent damage to the spinal cord. Having the patient bending forward or curled forward makes it easier to pass the spinal needle between the vertebrae. The needle is advanced until a faint "pop" is felt. The needle has now pierced the dura, the tough outermost covering of the central nervous system. The stylet in the spinal needle is removed and cerebral spinal fluid (CSF) begins to flow.
A manometer is sometimes attached to the spinal needle to measure the pressure of the CSF. 3-4 tubes of fluid are obtained, each containing about 1 milliliter of CSF. The pressure, color, and clarity of the CSF may all give clues as to the diagnosis. The CSF is sent to the lab to be analyzed for the presence and number of both red (RBC) and white (WBC) blood cells. The number of WBC's are further divided into the type of WBC. If a SAH is suspected, the RBC count is performed on the 1st and 4th tubes to see if the number is the same or changing. The CSF is cultured for microorganisms, and examined under a microscope after being stained with dyes. The glucose and protein of the CSF is measured. Additional tests may be ordered if unusual infections are suspected.
I now offer all my patients the option of having their LP done with conscious sedation (CS). The agreeable patient (written informed consent) is placed on continuous monitoring of their heart rate, oxygen saturation and blood pressure. The drugs used vary, but all sedate the patient while maintaining spontaneous respirations. The ideal agent would have no effect of heart and lung function and wear off rapidly after the procedure is complete. CS is used in the ER for reduction of fractures and dislocation as well as LP. My personal preferred drug is Propofol. Despite the fact that this drug contributed to the death of Michael Jackson, it is safe and effective when used appropriately. In infants and young children, Ketamine may be used as an alternative to propofol.
Obese patients present a challenge in performing an LP and having conscious sedation. Ultrasound may aid the ER doc to find the anatomic guideposts that are hidden under adipose tissue. Severely obese patients are more likely to have respiratory compromise from CS because of the restriction of their body weight on their chest muscles and diaphragm.
In the northeast, where I work, summer is encephalitis season. Meningitis and SAH can occur at any time. The ER staff is ready and able to properly diagnose and treat patients with the headache that may be the BIG ONE.
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