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.