Tomorrow is Halloween. I will be working my usual night shift. I fear that my fellow B.O.N.E.R. doc, Zorba, will have the scarier time tonight. Young adults and older teens use the occasion for excessive drinking, drugging and hormonally fueled shenanigans. Costumes, alcohol, parties, and hell raising are guaranteed to bump up the ER census.
My wife loves to hand out the packaged candy to the local kids. Our neighborhood contains many families with young children. Frightening tales of tampered goodies with poisons, needles and medications require that treats must be commercially produced and dispensed in their original wrappings. Earlier in my career, the ER offered to x-rays treat-bags to ensure that no metallic foreign bodies had been secreted into the candy.
The tricks of Halloween usually are benign and stale; egging, "TP ing", and flaming dog poop bags are common pranks. More innovative tricks such as hallucinogens in the cider, can swamp the ER with spaced out patients dressed as witches, devils, and assorted celebrities.
The application and adornment of the physiognomy of the Halloween party goer may lead to visits to the ER. Superglue is often used to attach horns and other embellishments. The problem arises when the glue gets into the eyes or near the nether regions. Removing the glued-on bits may cause avulsion of the underlying skin. OUCH!
In the Northeast, where I reside, hypothermia is also a risk during Halloween revelries. Costumes are often skimpy in their coverage and wearing a coat would ruin the ensemble. The effects of alcohol contribute to the hypothermia potential. Alcohol irritates the esophagous and stomach giving the imbiber a sense of inner heat. The vasodilating effects of alcohol cause increased heat loss from the skin and more rapid lowering of the core body temperature.
The truly tragic aspect of Halloween is the four fold increase, in auto-pedestrian accidents involving children, compared to the other 364 days of the year. Parents be advised, make your child visible and keep their own vision unencumbered. Glow sticks and necklaces, flashing LED lights, and reflective material are all excellent measures to make your child visible to drivers. Avoid masks and hoods that can limit the child's visual field. Drivers need to be extra cautious. The aftermath of injuring or killing a child are devastating for the victim's family and for the driver.
I do not wish to spoil the joy of Halloween. The world's oldest ER doc has fond memories of "trick or treat" ing with my friends back in the 1950's and 1960's. As a avid mimic, I would couple my costume with an appropriate accent. My mother's jodhpurs, and riding boots (she was a volunteer in the Women's Army Aircorp during WW 2) were paired with a puffy white shirt, monocle and my best British accent. A dhoti (Indian garment), begging bowl and an accent I learned from the movie, "Gunga Din" transformed me into Gandhi.
Today, October 30, is my twin sister's birthday. Yes, our birthdates are 28 days and almost 2 years apart. Think Danny Devito and the Arnold in the movie "Twins". No one embraces the joy and exuberance of the holiday more than my friend and spiritual twin, Joanne. Happy Birthday sis!
Saturday, October 30, 2010
Saturday, October 23, 2010
Algia
Almost every ER patient complains of some type of pain. Cephalgia, neuralgia, arthralgia refer to head, nerve and joint pain respectively. The root algia is from Latin. Angina from the Latin for choking also is used for several painful conditions. Angina pectoris is the term for pain in the chest from narrowing or blockages of the coronary arteries. Intestinal angina is used to describe pain from narrowing or blockages in the arteries that supply the GI tract. Ludwig's angina is severe throat pain from an infection in the mouth or throat that spreads towards the chest through the fascial plains of the neck. Colic is another medical term for pain that were thought to occur from intestinal sources. It's three types are infant (general crankiness without another source), renal (from the passage of a kidney stone) and biliary (from gall stones or bile sludge).
Pain is a protective mechanism. If one touches something hot, a reflex arc in the central nervous system causes withdrawal from the source of the heat even before we become fully aware of the pain. Noniceptors in the peripheral nervous system respond to heat, cold, pressure and sharp stimuli. These pain signals are carried to the brain by tracts in the spinal cord. The brain processes the information that one consciously perceives as pain.
Pain from an injury is from an obvious source and will resolve as the injury heals. A broken ankle will cause severe pain. Elevating and immobilizing the injured part with give some relief. As the fracture heals the pain will lessen and eventually resolve with complete healing. Similarly pain from an intrabdominal infection or from colic will resolve after appropriate treatment.
Treating acute pain is an important part of ER care. Unfortunately many physicians under treat acute pain. I have become much more "generous" in treating acute pain after my experiences as a patient with four major abdominal surgeries. PCA or patient controlled analgesia gives the pain sufferer, usually post-operative, the means to obtain IV pain meds by pushing a button. The amount and time interval between doses are set and locked. My only use of PCA was a failure. When I told the anesthesiologist (PCA may also be ordered by the surgeon) that the dose was too low and that I was getting little if any relief, he assured me that the dose was adequate.
Conscious sedation is used in the ER for patient comfort during painful procedures such as reducing fractures or dislocations, incising and draining an abscess or for a lumbar puncture. The drugs used for this sedation may include short acting pain medications such as fentanyl. A short acting benzodiazepine sedative such as midazolam is often combined with fentanyl to provide sedation with pain control. I prefer propofol. This drug causes a dissociation between the painful procedure and the perception of the pain. It's short duration and lack of long term side effects make it a valuable asset for the ER doc.
There are three main types of pain medications. NSAID's include ibuprofen, naprosyn, ketorolac and others. Acetaminophen is also a mild analgesic that may be taken solely or combined with an opiate. NSAID's are very effective for most mild to moderate short term painful conditions. Toothaches, menstrual cramps, minor orthopedic injuries and most headaches respond well to NSAID's. Moderate to severe pain usually require the third class of pain meds, opiates.
Opiates work by binding to the mu receptors in the nervous system. These receptors are widespread and are the target for our intrinsically made pain suppressors, endorphins. Anyone who has hit the "runner's high" during a prolonged workout has felt the effects of endorphins. The placebo effect is relief from the pain and other symptoms of disease or injury by an inert "sugar" pill. The belief that one is receiving treatment may cause the release of endorphins and explain the placebo effect.
Heroin, opium, morphine, codeine, hydromorphone, methadone, hydrocodone and oxycodone are all derived from the alkaloids obtained from the opium poppy. Other medications in the opiate group include meperidine, propoxyphene and fentanyl. Pills, liquids, patches, suppositories and injections are all ways of introducing these medications into the body. When given in adequate amounts for a limited time, opiates are both effective and safe.
The problems arise with pain that is never ending and psychological issues that effect pain perception. Neuralgia or nerve pain can last a lifetime and be debilitating. Damage to nerves from injury, infections (shingles), or metabolic diseases (diabetic neuropathy) may lead to constant pain. Pain from arthritis or disc disease may not resolve with treatment of the underlying condition. Phantom pain from amputated limbs is common and may be permanent. Pain from cancer is another example of the need for chronic pain management.
Patients with depression have an altered perception of pain. The flip side to this is that chronic pain may lead to depression. Antidepressants are often used with other medications to treat some forms of chronic pain. Anticonvulsants such as gabapentin have been used to treat neuropathic pain. Psychological counseling, physical therapy and exercise are also tools in the holistic approach to chronic pain management. It is important that patients with chronic pain be given long acting pain medications such as methadone, prolonged released morphine or fentanyl patches. A short acting medication such as hydrocodone or oxycodone should be available for acute exacerbations of the underlying chronic pain. The physician must take tolerance into account, and be willing to gradually increase the dose of the long acting medication as needed.
Physicians must accept some of the blame for the abuse of opiate pain medications by patients. Giving too little medication, for less time than is required for healing, will force the patient to try and find relief somewhere else. Some physicians give too strong an analgesic and this may lead to tolerance. Tolerance and addiction are the downside of opiate medications. There is evidence that the number of mu receptors increases in patients taking opiate medication for a prolonged period of time. The need for greater doses of pain meds to achieve the same level of relief (tolerance) may be the result of the increased number of mu receptors. The symptoms of withdrawal from opiates are all too real. The "screaming" of the mu receptors "feed me" is what makes withdrawal a living hell.
Drug seekers are the bane of an ER doc's existence. The causes of the pain may be genuine but their drug addiction makes them a drain on the time and patience of the ER staff. It is sometimes difficult to separate the patients with pain and the addicts looking to score. I have received letters, from various regulatory agencies, telling me that a patient who I prescribed opiate pain meds had received multiple prescriptions from multiple doctors. Multiple ER visits for minor problems, "allergies" to every drug except the one they want, and reported pain out of proportion to the injury, all may be indicative of the drug seeker. Threats to "call my lawyer" and verbal and physical assaults also are the signs of drug seeking behavior.
When I graduated from medical school in 1977, I didn't take the Hippocratic oath. My classmates and I took the Oath of Maimonides instead. "In the sufferer, let me see the human being."
Pain is a protective mechanism. If one touches something hot, a reflex arc in the central nervous system causes withdrawal from the source of the heat even before we become fully aware of the pain. Noniceptors in the peripheral nervous system respond to heat, cold, pressure and sharp stimuli. These pain signals are carried to the brain by tracts in the spinal cord. The brain processes the information that one consciously perceives as pain.
Pain from an injury is from an obvious source and will resolve as the injury heals. A broken ankle will cause severe pain. Elevating and immobilizing the injured part with give some relief. As the fracture heals the pain will lessen and eventually resolve with complete healing. Similarly pain from an intrabdominal infection or from colic will resolve after appropriate treatment.
Treating acute pain is an important part of ER care. Unfortunately many physicians under treat acute pain. I have become much more "generous" in treating acute pain after my experiences as a patient with four major abdominal surgeries. PCA or patient controlled analgesia gives the pain sufferer, usually post-operative, the means to obtain IV pain meds by pushing a button. The amount and time interval between doses are set and locked. My only use of PCA was a failure. When I told the anesthesiologist (PCA may also be ordered by the surgeon) that the dose was too low and that I was getting little if any relief, he assured me that the dose was adequate.
Conscious sedation is used in the ER for patient comfort during painful procedures such as reducing fractures or dislocations, incising and draining an abscess or for a lumbar puncture. The drugs used for this sedation may include short acting pain medications such as fentanyl. A short acting benzodiazepine sedative such as midazolam is often combined with fentanyl to provide sedation with pain control. I prefer propofol. This drug causes a dissociation between the painful procedure and the perception of the pain. It's short duration and lack of long term side effects make it a valuable asset for the ER doc.
There are three main types of pain medications. NSAID's include ibuprofen, naprosyn, ketorolac and others. Acetaminophen is also a mild analgesic that may be taken solely or combined with an opiate. NSAID's are very effective for most mild to moderate short term painful conditions. Toothaches, menstrual cramps, minor orthopedic injuries and most headaches respond well to NSAID's. Moderate to severe pain usually require the third class of pain meds, opiates.
Opiates work by binding to the mu receptors in the nervous system. These receptors are widespread and are the target for our intrinsically made pain suppressors, endorphins. Anyone who has hit the "runner's high" during a prolonged workout has felt the effects of endorphins. The placebo effect is relief from the pain and other symptoms of disease or injury by an inert "sugar" pill. The belief that one is receiving treatment may cause the release of endorphins and explain the placebo effect.
Heroin, opium, morphine, codeine, hydromorphone, methadone, hydrocodone and oxycodone are all derived from the alkaloids obtained from the opium poppy. Other medications in the opiate group include meperidine, propoxyphene and fentanyl. Pills, liquids, patches, suppositories and injections are all ways of introducing these medications into the body. When given in adequate amounts for a limited time, opiates are both effective and safe.
The problems arise with pain that is never ending and psychological issues that effect pain perception. Neuralgia or nerve pain can last a lifetime and be debilitating. Damage to nerves from injury, infections (shingles), or metabolic diseases (diabetic neuropathy) may lead to constant pain. Pain from arthritis or disc disease may not resolve with treatment of the underlying condition. Phantom pain from amputated limbs is common and may be permanent. Pain from cancer is another example of the need for chronic pain management.
Patients with depression have an altered perception of pain. The flip side to this is that chronic pain may lead to depression. Antidepressants are often used with other medications to treat some forms of chronic pain. Anticonvulsants such as gabapentin have been used to treat neuropathic pain. Psychological counseling, physical therapy and exercise are also tools in the holistic approach to chronic pain management. It is important that patients with chronic pain be given long acting pain medications such as methadone, prolonged released morphine or fentanyl patches. A short acting medication such as hydrocodone or oxycodone should be available for acute exacerbations of the underlying chronic pain. The physician must take tolerance into account, and be willing to gradually increase the dose of the long acting medication as needed.
Physicians must accept some of the blame for the abuse of opiate pain medications by patients. Giving too little medication, for less time than is required for healing, will force the patient to try and find relief somewhere else. Some physicians give too strong an analgesic and this may lead to tolerance. Tolerance and addiction are the downside of opiate medications. There is evidence that the number of mu receptors increases in patients taking opiate medication for a prolonged period of time. The need for greater doses of pain meds to achieve the same level of relief (tolerance) may be the result of the increased number of mu receptors. The symptoms of withdrawal from opiates are all too real. The "screaming" of the mu receptors "feed me" is what makes withdrawal a living hell.
Drug seekers are the bane of an ER doc's existence. The causes of the pain may be genuine but their drug addiction makes them a drain on the time and patience of the ER staff. It is sometimes difficult to separate the patients with pain and the addicts looking to score. I have received letters, from various regulatory agencies, telling me that a patient who I prescribed opiate pain meds had received multiple prescriptions from multiple doctors. Multiple ER visits for minor problems, "allergies" to every drug except the one they want, and reported pain out of proportion to the injury, all may be indicative of the drug seeker. Threats to "call my lawyer" and verbal and physical assaults also are the signs of drug seeking behavior.
When I graduated from medical school in 1977, I didn't take the Hippocratic oath. My classmates and I took the Oath of Maimonides instead. "In the sufferer, let me see the human being."
Friday, October 15, 2010
Plus ca change
The more things change, the more they stay the same. It sounds classier in the original French. I was somewhat blocked as to a subject for today's blog. While waiting in line at Starbucks, I ran into an old friend. This gentleman is 11 years older than me. He went into medicine in his 40's after a career of writing. He and I worked together in the ER where I still practice. He was forced out and went to work in a small town in Vermont with an ER that sees 1/5 the volume of my hospital. He is approaching seventy and still going strong. I am only hoping to get to 67 before retiring.
There are quirks of ER practice that occur repeatedly. New generations of patients still have the same odd behaviors. The numbers keep going up and the mix of patients varies but somethings stay the same.
"I have this pain in my back for a month." After sliently groaning, I try not to roll my eyes and ready my questions. Bladder function, bowel habits, fever, chills, numbness, weakness... "I have an appointment with my primary care at 11:00 but I couldn't wait any longer." This is said to me at 2:00 AM. Why? The patient waited weeks to get an appointment but was unable to wait an additional 8 hours.
I approach a lovely woman in her eighties. The chief complaint is abdominal pain. "What is the problem tonight?" I ask with some trepidation. She begins her story in 1936. She regales me with issues from the Great Depression, WW2, her marriage and children. An older gentleman responds to the same question by taking out a notebook that details everything he has eaten in the past 6 month and how his body reacted to each and every meal.
A mother and infant on the stretcher resembling a renaissance painting of the Madonna and child. The chief complaint is fever and a runny nose. I ask what she gave for the baby's fever and she says "nothing, I brought him to the ER". In loco parentis. ER's have become substitute parents. This is especially true of first-time teen mothers. My dear friend Elizabeth, was an ER nurse who trained at Children's Hospital. She cared for the baby and gently educated the mother.
Vomiting and eating is a recurrent issue in the ER. The toddler who is in the ER for vomiting is being fed cheese puffs by his mother while seated on the stretcher. The first thing a patient who is retching in the barf bag asks is, "can I have something to drink?".
0600 on a Tuesday morning, after a three day weekend. The bus has arrived. Five patients in triage for mild complaints. The hidden agenda is the doctor issued work note. Mr Jones skipped work on Friday and now needs a note to justify his absence. Citizens who have scheduled court appearances also seem to develop vague symptoms early in the morning of their court date.
The patient generated diagnosis is usually from a visit to WebMD prior to arriving in the ER. When a young man tells me that he has Lupus, when I see a contact dermatitis on his face from his new cologne, I know that the internet is to blame. The appropriate cliche is "a little knowledge is dangerous". The herd of zebras that thunder through the ER is driven by various web pages devoted to empowering the patient. I am told what tests and scans that the patient feels he or she needs. I gaze over my reading glasses and try and explain a more rational approach to finding a cause of their listed symptoms.
My colleagues in primary care and other fields of medicine contribute to the cavalcade of self diagnosing and self ordering by my patients. "My pediatrician says Susie needs a CAT scan because her stomach ache could be appendicitis." "Jimmy has a headache and my doctor said it could be meningitis, so I want him to have a spinal tap." Susie is playing her video game while scarfing down an ice cream sandwich, and Jimmy was seen running around the waiting room and yelling at the other patients.
As my good friend Clyde pointed out to me over a cup of good coffee, plus ca change, plus c'est la meme chose.
There are quirks of ER practice that occur repeatedly. New generations of patients still have the same odd behaviors. The numbers keep going up and the mix of patients varies but somethings stay the same.
"I have this pain in my back for a month." After sliently groaning, I try not to roll my eyes and ready my questions. Bladder function, bowel habits, fever, chills, numbness, weakness... "I have an appointment with my primary care at 11:00 but I couldn't wait any longer." This is said to me at 2:00 AM. Why? The patient waited weeks to get an appointment but was unable to wait an additional 8 hours.
I approach a lovely woman in her eighties. The chief complaint is abdominal pain. "What is the problem tonight?" I ask with some trepidation. She begins her story in 1936. She regales me with issues from the Great Depression, WW2, her marriage and children. An older gentleman responds to the same question by taking out a notebook that details everything he has eaten in the past 6 month and how his body reacted to each and every meal.
A mother and infant on the stretcher resembling a renaissance painting of the Madonna and child. The chief complaint is fever and a runny nose. I ask what she gave for the baby's fever and she says "nothing, I brought him to the ER". In loco parentis. ER's have become substitute parents. This is especially true of first-time teen mothers. My dear friend Elizabeth, was an ER nurse who trained at Children's Hospital. She cared for the baby and gently educated the mother.
Vomiting and eating is a recurrent issue in the ER. The toddler who is in the ER for vomiting is being fed cheese puffs by his mother while seated on the stretcher. The first thing a patient who is retching in the barf bag asks is, "can I have something to drink?".
0600 on a Tuesday morning, after a three day weekend. The bus has arrived. Five patients in triage for mild complaints. The hidden agenda is the doctor issued work note. Mr Jones skipped work on Friday and now needs a note to justify his absence. Citizens who have scheduled court appearances also seem to develop vague symptoms early in the morning of their court date.
The patient generated diagnosis is usually from a visit to WebMD prior to arriving in the ER. When a young man tells me that he has Lupus, when I see a contact dermatitis on his face from his new cologne, I know that the internet is to blame. The appropriate cliche is "a little knowledge is dangerous". The herd of zebras that thunder through the ER is driven by various web pages devoted to empowering the patient. I am told what tests and scans that the patient feels he or she needs. I gaze over my reading glasses and try and explain a more rational approach to finding a cause of their listed symptoms.
My colleagues in primary care and other fields of medicine contribute to the cavalcade of self diagnosing and self ordering by my patients. "My pediatrician says Susie needs a CAT scan because her stomach ache could be appendicitis." "Jimmy has a headache and my doctor said it could be meningitis, so I want him to have a spinal tap." Susie is playing her video game while scarfing down an ice cream sandwich, and Jimmy was seen running around the waiting room and yelling at the other patients.
As my good friend Clyde pointed out to me over a cup of good coffee, plus ca change, plus c'est la meme chose.
Saturday, October 9, 2010
ITIS
A beautiful fall day and I have an aching left shoulder. Tendinitis or bursitis. Popping aspirin helps. I know exactly how this injury occurred. A poorly done weight training session, one day after turning 58, caused this "itis".
Arthralgias, joint pains, are divided medically into inflammatory and non-inflammatory subsets. Rheumatoid arthritis is the poster child for inflammatory joint disease. The body's immune system attacks the components of the joints with pain, swelling and ultimately destruction of the joint. Anti-inflammatory medications such as aspirin and NSAID's have always been part of the treatment. Immune modulators are the newest and most beneficial treatment modalities. The side effects of this immunotherapy are an increased risk of infections and cancer.
Osteoarthritis is the most common form of joint disease. There is a familial risk of the more severe form of the condition. Wear and tear of the joints from work and recreational stresses make all of us susceptible to OA. Our bones may get thicker as we gain weight but our joints don't get larger or more robust from added body weight. Arthritis, leading to joint replacement, is increasing because of the epidemic of obesity in our nation.
Joint pains may also be caused by injury and inflammation of tendons, ligaments and bursas near joints. My shoulder pain is most likely tendinitis of the biceps tendon. Bursitis is a possibility. Bursas are sacs that help lubricate the tendons and bones around the large joints. A plain x-ray of an aching shoulder may reveal calcification in the bursa from chronic inflammation. Those calcium crystals are like microscopic knifes, stabbing at the tender lining of the bursa.
NSAID's are the first line of treatment for all the "itises" in or around the joints. Rest, ice, creams such as Icy Hot may give additional relief from pain. A well placed shot of a corticosteroid by a physician is the best long term treatment. I am contemplating a visit to my favorite orthopedic surgeon, "the Czar", even as I write this blog.
Another condition that causes joint pains is nerve impingement. Carpal tunnel syndrome is pain in the wrist with numbness, and pain in the fingers from injury to the median nerve, as it courses through the wrist bones (carpal tunnel). Repetitive motions such as typing, assembly work and carpentry may lead to swelling in the carpal tunnel and pressure on the median nerve. Nerve impingement can also occur at the elbow, knee and ankle. Temporary relief with splints, anti-inflammatory medications and avoidance of the mechanical cause is possible. Surgery is often necessary and curative.
As we age, our joints simply wear out. Our bones thin, our muscles become weaker, and our connective tissue becomes less flexible. Arthritis is part of the natural aging process. There is no cure, despite the many "snake oil" sellers in newspapers, magazines and especially on the internet. There is no scientific evidence that glucosamine and/or condroitin alleviate or arrest the progression of arthritis. Ditto for shark cartilage, "super fruits", and assorted creams and lotions. Maintaining an "ideal" body weight, regular low impact exercise, and a good night's sleep are your best weapons in the fight against degenerative joint disease.
I feel obliged to mention a disease that makes ER docs cringe when listed on a patient's medical history, Fibromyalgia. Back in the mid 70's, as a medical student I had an instructor named John J Calabro, MD. Dr Calabro was a rheumatologist. He was a dedicated teacher and a compassionate physician. He also wrote one of the earliest treatises on a condition known as fibromyalgia. I remember him telling me that the woman he married had been one of his patients, who he diagnosed with fibromyalgia.
Muscle fiber pain is a loose English translation for fibromyalgia. As with Chronic Fatigue Syndrome and Chronic Lyme disease, two other conditions associated with severe and long term muscle and joint pains, there exists no specific lab test to confirm the diagnosis. Tests for lupus, rheumatoid arthritis and general inflammatory markers are all negative/normal in fibromyalgias. The disease is diagnosed by objective criteria. Harrison's textbook of medicine describes fibromyalgia as a "common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesias, disturbed sleep and easy fatigability along with multiple tender points". The tender points are usually symmetric and number more than three. The upper back, shoulders and neck are common sites. This heightened (exaggerated?) and painful response to applied pressure is the hallmark of fibromyalgia. The ratio or women to men with fibromyalgia is 9:1. Certain anti-convulsants and anti-depressants, anti-inflammatories, "trigger point" steroid injections and long term opiate pain medications are used to treat fibromyalgia.
Improved sleep, exercise, weight loss and stress reduction have all proven helpful in treating fibromyalgia. In patients under fifty, fibromyalgia is the most common diagnosis for musculoskeletal pain. Despite my respect for Dr Calabro, I remain an agnostic concerning fibromyalgia. research into the levels of neurotransmitters in the pain-sensing portions of the brain may ultimately confirm the cause of this condition. Stay tuned!
Arthralgias, joint pains, are divided medically into inflammatory and non-inflammatory subsets. Rheumatoid arthritis is the poster child for inflammatory joint disease. The body's immune system attacks the components of the joints with pain, swelling and ultimately destruction of the joint. Anti-inflammatory medications such as aspirin and NSAID's have always been part of the treatment. Immune modulators are the newest and most beneficial treatment modalities. The side effects of this immunotherapy are an increased risk of infections and cancer.
Osteoarthritis is the most common form of joint disease. There is a familial risk of the more severe form of the condition. Wear and tear of the joints from work and recreational stresses make all of us susceptible to OA. Our bones may get thicker as we gain weight but our joints don't get larger or more robust from added body weight. Arthritis, leading to joint replacement, is increasing because of the epidemic of obesity in our nation.
Joint pains may also be caused by injury and inflammation of tendons, ligaments and bursas near joints. My shoulder pain is most likely tendinitis of the biceps tendon. Bursitis is a possibility. Bursas are sacs that help lubricate the tendons and bones around the large joints. A plain x-ray of an aching shoulder may reveal calcification in the bursa from chronic inflammation. Those calcium crystals are like microscopic knifes, stabbing at the tender lining of the bursa.
NSAID's are the first line of treatment for all the "itises" in or around the joints. Rest, ice, creams such as Icy Hot may give additional relief from pain. A well placed shot of a corticosteroid by a physician is the best long term treatment. I am contemplating a visit to my favorite orthopedic surgeon, "the Czar", even as I write this blog.
Another condition that causes joint pains is nerve impingement. Carpal tunnel syndrome is pain in the wrist with numbness, and pain in the fingers from injury to the median nerve, as it courses through the wrist bones (carpal tunnel). Repetitive motions such as typing, assembly work and carpentry may lead to swelling in the carpal tunnel and pressure on the median nerve. Nerve impingement can also occur at the elbow, knee and ankle. Temporary relief with splints, anti-inflammatory medications and avoidance of the mechanical cause is possible. Surgery is often necessary and curative.
As we age, our joints simply wear out. Our bones thin, our muscles become weaker, and our connective tissue becomes less flexible. Arthritis is part of the natural aging process. There is no cure, despite the many "snake oil" sellers in newspapers, magazines and especially on the internet. There is no scientific evidence that glucosamine and/or condroitin alleviate or arrest the progression of arthritis. Ditto for shark cartilage, "super fruits", and assorted creams and lotions. Maintaining an "ideal" body weight, regular low impact exercise, and a good night's sleep are your best weapons in the fight against degenerative joint disease.
I feel obliged to mention a disease that makes ER docs cringe when listed on a patient's medical history, Fibromyalgia. Back in the mid 70's, as a medical student I had an instructor named John J Calabro, MD. Dr Calabro was a rheumatologist. He was a dedicated teacher and a compassionate physician. He also wrote one of the earliest treatises on a condition known as fibromyalgia. I remember him telling me that the woman he married had been one of his patients, who he diagnosed with fibromyalgia.
Muscle fiber pain is a loose English translation for fibromyalgia. As with Chronic Fatigue Syndrome and Chronic Lyme disease, two other conditions associated with severe and long term muscle and joint pains, there exists no specific lab test to confirm the diagnosis. Tests for lupus, rheumatoid arthritis and general inflammatory markers are all negative/normal in fibromyalgias. The disease is diagnosed by objective criteria. Harrison's textbook of medicine describes fibromyalgia as a "common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesias, disturbed sleep and easy fatigability along with multiple tender points". The tender points are usually symmetric and number more than three. The upper back, shoulders and neck are common sites. This heightened (exaggerated?) and painful response to applied pressure is the hallmark of fibromyalgia. The ratio or women to men with fibromyalgia is 9:1. Certain anti-convulsants and anti-depressants, anti-inflammatories, "trigger point" steroid injections and long term opiate pain medications are used to treat fibromyalgia.
Improved sleep, exercise, weight loss and stress reduction have all proven helpful in treating fibromyalgia. In patients under fifty, fibromyalgia is the most common diagnosis for musculoskeletal pain. Despite my respect for Dr Calabro, I remain an agnostic concerning fibromyalgia. research into the levels of neurotransmitters in the pain-sensing portions of the brain may ultimately confirm the cause of this condition. Stay tuned!
Friday, October 1, 2010
Germs Chapter 3, The Deadly Viruses
There exist many viruses that are lethal or at best controllable. HIV, rabies, and hemorrhagic fevers all are included in the "deadly viruses".
Rabies is caused by a rhabdovirus. There is a large reservoir of rabies in the animal kingdom. In the US, bats, raccoons, skunks, coyotes and foxes are common sources. Any predator animal and even some large prey animals may harbor rabies. Bites, scratches and even saliva may transmit the virus. Animals who are infected die. The viral inoculation occurs at the site of penetration. The virus travels up the local peripheral nerves and eventually makes its way into the central nervous system ultimately causing encephalitis and death. Infected animal often display abnormal behavior. Aggression and unprovoked attacks may be evident. During the late stages, the infected animal or human has difficulty swallowing. The drooling saliva from this dysphagia gave rise to the term hydrophobia (fear of water) to describe rabies.
Rabies is not universally fatal. There have been a few victims who survived. The Milwaukee protocol arose from the survival of a young woman after she became infected with rabies. The treatment involved a drug induced coma. Ketamine, midazolam and phenobarbital were used to place the patient in a coma. Antiviral medication (ribavirin and amantadine) were given intravenously. The patient has made a remarkable recovery. Other factors may have aided her survival. The bite was in her finger. The strain of the virus may have been weak.
The treatment of rabies involves giving passive immunity by injecting RIG (rabies immune globulin) into the area of the bite and into the large muscles of the buttocks. The amount of RIG is based on the patient's weight. Stimulating active immunity is done by giving rabies vaccine in several doses over the course of a month. This treatment can have painful and even serious medical side effects. If the source animal can be tested and found to not have rabies, the human victim may be spared those many injections.
Don't feed or even approach feral animals. Dogs in the US rarely harbor rabies. Feral cats are a potential source. Be careful and notify animal control as soon as possible.
Viral hemorrhagic fevers include Crimean-Congo, Rift Valley and South American strains. The filoviruses that cause Ebola and Marburg also cause hemorrhagic illnesses. The symptoms include fever, petechiae, mucosal and gastrointestinal bleeding. Severe headaches, hypotension and vomiting and diarrhea occur. The only treatment is supportive care with hydration, blood products and careful monitoring. The mortality rate is high.
Yellow fever, and Dengue are caused by flaviviruses. They cause liver damage, with jaundice being evident (yellowing of the skin and conjuctiva). Black vomitous is often seen in Yellow fever. There is a vaccine available for these diseases and if you are traveling to areas that are endemic for them, you should get the vaccination. Mosquitoes are the carrier for all the hemorrhagic fevers. Use of bed netting and avoidance of mosquitoes are good practices in endemic regions.
As an emergency medicine resident back in the late 70's, I saw a few young men with purple colored skin lesions. The had fevers, weight loss, unusual infections such as pneumocystis pneumonia. The skin lesions were shown by biopsy to be Karposi sarcoma. I had read in my pathology text that this cancer was usually seen in elderly men from the Mediterranean area.
AIDS was the name given to the constellation of diseases caused by HIV. The virus was subsequently identified as a lentivirus. This retrovirus uses RNA as its genetic material. After thirty years of research, no effective vaccine to prevent HIV infection exists. HIV binds to and kills a type of lymphocyte that is involved with human cellular immunity. The infections and cancers that make up AIDS, arise because of the damage to the patient's immune system.
The early history of HIV/AIDS was of horrible, wasting death. Although not curable, HIV/AIDS has become a chronic manageable disease. HAART is highly active antiretroviral therapy. This treatment uses medication that attack the virus in several ways. Nucleoside Reverse Transcriptase and non-Nucleoside Reverse Transcriptase inhibitors interfere with the virus's ability to copy its RNA. Protease, entry, and integrase inhibitors work by other mechanisms to hinder the HIV. The patients are followed with blood tests to monitor their viral load and CD4 lymphocyte counts. These potent medications have significant side effects. They must be taken faithfully. Unfortunately, the incidence of HIV is increasing because of continued unsafe sex practices and IV drug abuse.
HIV exposure from occupational needle sticks or unprotected sexual contact can be treated with PEP (post-exposure prophylaxis). This involves taking anti-retrovirus medication for several weeks. It is effective but the side effects of the medications make it difficult to complete the treatment.
Hepatitis C is caused by a single strand RNA virus. It is spread by contaminated needles or blood exposure. There is a treatment involving pegylated interferon and ribavirin. The treatment doesn't work for all patients and the side effects of the medications may prevent completion of the treatment course. Hepatitis C often leads to cirrhosis and hepatocellular carcinoma many years after the initial infection. The blood supply is no longer a source of this disease. IV drug abuse and occupational exposure to infected blood are the main sources.
I find it humbling that the simplest living organisms (viruses) cause so much human illness. Our overpopulation and encroachment into all environments on this small planet have exposed us to many of these scourges. Knowledge and research are the best chance for our overcoming these diseases. Stay informed, practice safe sex, if you use IV drugs, avail yourself of clean needle exchange programs. When traveling, check with the CDC for advisories concerning diseases in the areas you are visiting.
Rabies is caused by a rhabdovirus. There is a large reservoir of rabies in the animal kingdom. In the US, bats, raccoons, skunks, coyotes and foxes are common sources. Any predator animal and even some large prey animals may harbor rabies. Bites, scratches and even saliva may transmit the virus. Animals who are infected die. The viral inoculation occurs at the site of penetration. The virus travels up the local peripheral nerves and eventually makes its way into the central nervous system ultimately causing encephalitis and death. Infected animal often display abnormal behavior. Aggression and unprovoked attacks may be evident. During the late stages, the infected animal or human has difficulty swallowing. The drooling saliva from this dysphagia gave rise to the term hydrophobia (fear of water) to describe rabies.
Rabies is not universally fatal. There have been a few victims who survived. The Milwaukee protocol arose from the survival of a young woman after she became infected with rabies. The treatment involved a drug induced coma. Ketamine, midazolam and phenobarbital were used to place the patient in a coma. Antiviral medication (ribavirin and amantadine) were given intravenously. The patient has made a remarkable recovery. Other factors may have aided her survival. The bite was in her finger. The strain of the virus may have been weak.
The treatment of rabies involves giving passive immunity by injecting RIG (rabies immune globulin) into the area of the bite and into the large muscles of the buttocks. The amount of RIG is based on the patient's weight. Stimulating active immunity is done by giving rabies vaccine in several doses over the course of a month. This treatment can have painful and even serious medical side effects. If the source animal can be tested and found to not have rabies, the human victim may be spared those many injections.
Don't feed or even approach feral animals. Dogs in the US rarely harbor rabies. Feral cats are a potential source. Be careful and notify animal control as soon as possible.
Viral hemorrhagic fevers include Crimean-Congo, Rift Valley and South American strains. The filoviruses that cause Ebola and Marburg also cause hemorrhagic illnesses. The symptoms include fever, petechiae, mucosal and gastrointestinal bleeding. Severe headaches, hypotension and vomiting and diarrhea occur. The only treatment is supportive care with hydration, blood products and careful monitoring. The mortality rate is high.
Yellow fever, and Dengue are caused by flaviviruses. They cause liver damage, with jaundice being evident (yellowing of the skin and conjuctiva). Black vomitous is often seen in Yellow fever. There is a vaccine available for these diseases and if you are traveling to areas that are endemic for them, you should get the vaccination. Mosquitoes are the carrier for all the hemorrhagic fevers. Use of bed netting and avoidance of mosquitoes are good practices in endemic regions.
As an emergency medicine resident back in the late 70's, I saw a few young men with purple colored skin lesions. The had fevers, weight loss, unusual infections such as pneumocystis pneumonia. The skin lesions were shown by biopsy to be Karposi sarcoma. I had read in my pathology text that this cancer was usually seen in elderly men from the Mediterranean area.
AIDS was the name given to the constellation of diseases caused by HIV. The virus was subsequently identified as a lentivirus. This retrovirus uses RNA as its genetic material. After thirty years of research, no effective vaccine to prevent HIV infection exists. HIV binds to and kills a type of lymphocyte that is involved with human cellular immunity. The infections and cancers that make up AIDS, arise because of the damage to the patient's immune system.
The early history of HIV/AIDS was of horrible, wasting death. Although not curable, HIV/AIDS has become a chronic manageable disease. HAART is highly active antiretroviral therapy. This treatment uses medication that attack the virus in several ways. Nucleoside Reverse Transcriptase and non-Nucleoside Reverse Transcriptase inhibitors interfere with the virus's ability to copy its RNA. Protease, entry, and integrase inhibitors work by other mechanisms to hinder the HIV. The patients are followed with blood tests to monitor their viral load and CD4 lymphocyte counts. These potent medications have significant side effects. They must be taken faithfully. Unfortunately, the incidence of HIV is increasing because of continued unsafe sex practices and IV drug abuse.
HIV exposure from occupational needle sticks or unprotected sexual contact can be treated with PEP (post-exposure prophylaxis). This involves taking anti-retrovirus medication for several weeks. It is effective but the side effects of the medications make it difficult to complete the treatment.
Hepatitis C is caused by a single strand RNA virus. It is spread by contaminated needles or blood exposure. There is a treatment involving pegylated interferon and ribavirin. The treatment doesn't work for all patients and the side effects of the medications may prevent completion of the treatment course. Hepatitis C often leads to cirrhosis and hepatocellular carcinoma many years after the initial infection. The blood supply is no longer a source of this disease. IV drug abuse and occupational exposure to infected blood are the main sources.
I find it humbling that the simplest living organisms (viruses) cause so much human illness. Our overpopulation and encroachment into all environments on this small planet have exposed us to many of these scourges. Knowledge and research are the best chance for our overcoming these diseases. Stay informed, practice safe sex, if you use IV drugs, avail yourself of clean needle exchange programs. When traveling, check with the CDC for advisories concerning diseases in the areas you are visiting.
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