I am sitting in a car dealership having a headlight replaced. Being a fine piece of German engineering, the bulb will cost $209 plus labor. I have been told that the bumper assembly must be entered to replace this Xenon bulb. The car I drive is 10 years old. It is a squat, unsexy wagon. It's appeal is safety. "Bruno" weighs in at 4000 + pounds, is all wheel drive, has front and side airbags and has a manual transmission. Driving to and from the ER earlier this week during a blizzard, reinforced one of the reasons I drive this vehicle. The main purpose of owning 2 tons of car is to allow me to survive an MVC (motor vehicle collision).
My ER is a level 3 trauma center. Weather permitting, an MVC patient having life threatening injuries, may be sent to one of the level 1 trauma center 30 miles from my area by helicopter. Most occupants of a car crash are brought to the regional level 3 hospital. The patients arrive on a board with a cervical collar in place. ALS (advanced life support) is rarely needed for victims of motor vehicle trauma. New evidence has supported the concept of scoop and run versus the ALS, stay and play. Thankfully automotive design has made cars, trucks, and vans safer for their occupants in a MVC.
When a patient from an MVC arrives in the ER, the nurses, doctors, techs and PA's do a primary assessment. Vital signs, airway, breathing and cardiovascular are rapidly performed. Pertinent information as to the patients medications, allergies, past medical and surgical history and last food and drink ingestion. An examination of the patient from head to toes will guide the ER staff in determining what labs, radiographic and other diagnostic tests need to be necessary. FAST examination (an ultrasound of the abdomen) may be done quickly and without moving the patient. A trauma surgeon may be called in or the patient may be stabilized for urgent transport to a higher level trauma center.
The most seriously injured patients from an MVC are those that are ejected from the vehicle. The single most important tool for survival is to wear a seat and shoulder belt. The details of the accident such as speed, area of impact, and rollover may give clues as to the type of injuries that the patients will have. Prolonged extrication times are also important as internal injuries with ongoing blood loss must be addressed as soon as possible.
There are strong guidelines as to the type of seat and its position for protecting babies and children in motor vehicles. Parents must use the correct seat type for the age and weight of their child. Belts and straps must be applied as recommended by the device and car manufacturer.
Winter is here. Snow, ice, wind make driving a challenge. Take your time. Appropriate speed is determined by the weather and road conditions, not the speed limit. Wear your seat belt. Protect your children. Maintain your car with winter tires, lots of window washer fluid and proper air pressure in your tires. If there is a storm advisory, stay home. Don't drive unless you have to. Bruno, my trusty tank, will get me to the ER. I will be there with my coworkers, ready to care for the victims of MVC's
Thursday, December 30, 2010
Friday, December 24, 2010
SAD
S.A.D is an acronym for seasonal affective disorder. This used to be referred to as the winter blues. Short days, long nights, cold, windy and snowy conditions make some feel blue. My beautiful wife will inevitably tell me that we must go somewhere warm and sunny during the long winters of the Northeast.
The holidays are also a source of winter depression. The joy and festive mood of the Christmas season reminds us of the loved ones who are not with us. Military personnel serving in war zones or on distant bases, family in far off cities, towns and foreign countries, and family and friends who have passed leave us bereft and aching.
The economy has idled millions of our fellow citizens. The number of Americans who have had their homes foreclosed is staggering. What parent wouldn't feel depressed when faced with a Christmas among strangers and no presents for their children.
I want to cure the winter blues. Isn't that what a physician is trained and sworn to do? SAD is treatable. Special whole spectrum lights can affect the parts of the brain that cause the sadness and lack of energy associated with SAD. In severe cases antidepressant medications may be prescribed and are usually effective.
In the ER, the number of psychiatric patients often increases around Christmas and New Year's. The staff provides a warm bed, food, a TV for entertainment and medications for our depressed, schizophrenic, bipolar, substance abusing patients. Their stay in the ER is prolonged because of the dearth of beds in the psychiatric hospitals.
To my gentle readers, I would make a request. Spread the joy of the holiday. Be kind to all you encounter. Donate food, clothes, toys and money. Volunteering costs you only some time and yet yields great rewards for the recipients and the givers. Be sensitive to those who are feeling the void of a missing loved one. Kind words, a hug if appropriate, and prayers if one is so motivated.
My wife and I will spend Christmas eve with family. Tomorrow we will visit my nonagenarian mother in the nursing home. "It's a wonderful life" is on TV tomorrow night. We will sit together, speak the dialogue along with Jimmy Steward and Donna Reed, and cry at the ending.
Merry Chistmas. Feliz Navidad. Chung Mung Giang Sinh. Boas Festose Feliz Ano Novo. Kala Christouyenna. Joyeux Noel. Soursdey Noel. Buone Feste Natalizie.
Peace on Earth!
The holidays are also a source of winter depression. The joy and festive mood of the Christmas season reminds us of the loved ones who are not with us. Military personnel serving in war zones or on distant bases, family in far off cities, towns and foreign countries, and family and friends who have passed leave us bereft and aching.
The economy has idled millions of our fellow citizens. The number of Americans who have had their homes foreclosed is staggering. What parent wouldn't feel depressed when faced with a Christmas among strangers and no presents for their children.
I want to cure the winter blues. Isn't that what a physician is trained and sworn to do? SAD is treatable. Special whole spectrum lights can affect the parts of the brain that cause the sadness and lack of energy associated with SAD. In severe cases antidepressant medications may be prescribed and are usually effective.
In the ER, the number of psychiatric patients often increases around Christmas and New Year's. The staff provides a warm bed, food, a TV for entertainment and medications for our depressed, schizophrenic, bipolar, substance abusing patients. Their stay in the ER is prolonged because of the dearth of beds in the psychiatric hospitals.
To my gentle readers, I would make a request. Spread the joy of the holiday. Be kind to all you encounter. Donate food, clothes, toys and money. Volunteering costs you only some time and yet yields great rewards for the recipients and the givers. Be sensitive to those who are feeling the void of a missing loved one. Kind words, a hug if appropriate, and prayers if one is so motivated.
My wife and I will spend Christmas eve with family. Tomorrow we will visit my nonagenarian mother in the nursing home. "It's a wonderful life" is on TV tomorrow night. We will sit together, speak the dialogue along with Jimmy Steward and Donna Reed, and cry at the ending.
Merry Chistmas. Feliz Navidad. Chung Mung Giang Sinh. Boas Festose Feliz Ano Novo. Kala Christouyenna. Joyeux Noel. Soursdey Noel. Buone Feste Natalizie.
Peace on Earth!
Saturday, December 18, 2010
Seven days til Christmas
Tis the week before Christmas and all through my mind,
Visions of moms with their kids; complaints of all kind:
Sniffles and coughs, fever and chills,
Spitting up, pooping, bumps and spills,
Swallowing toys, batteries, and herbage,
Infants and toddlers will eat any garbage.
The plants of the season give me concerns,
Mistletoe, poinsettias and even house ferns,
All can injure if chewed or ingested.
Holly especially is one to be detested:
20 berries to a child is a dose that may kill,
Vomiting, gasping, seizing; this is not a drill.
Take care with toys that have been painted,
With lead and cadmium, they could be tainted.
Sleds, skate, skis and snow boards make great presents,
Add a helmet for the young and even the parents.
Safety for my patients keeps me awake,
Thin ice may cause drowning for wee ones who skate.
Low temperature, wet and wind: frost bite is a real peril,
Layers of clothes, hats, scarves, mittens; warm winter apparel.
Hot toddies, egg nog and drinks for the season,
None for children and with good reason,
Alcohol is a poison even in small doses,
Take care of the partiers with curious noses.
But you'll hear me proclaim ere my words fade from sight,
Have a safe Christmas and to all a good night.
Visions of moms with their kids; complaints of all kind:
Sniffles and coughs, fever and chills,
Spitting up, pooping, bumps and spills,
Swallowing toys, batteries, and herbage,
Infants and toddlers will eat any garbage.
The plants of the season give me concerns,
Mistletoe, poinsettias and even house ferns,
All can injure if chewed or ingested.
Holly especially is one to be detested:
20 berries to a child is a dose that may kill,
Vomiting, gasping, seizing; this is not a drill.
Take care with toys that have been painted,
With lead and cadmium, they could be tainted.
Sleds, skate, skis and snow boards make great presents,
Add a helmet for the young and even the parents.
Safety for my patients keeps me awake,
Thin ice may cause drowning for wee ones who skate.
Low temperature, wet and wind: frost bite is a real peril,
Layers of clothes, hats, scarves, mittens; warm winter apparel.
Hot toddies, egg nog and drinks for the season,
None for children and with good reason,
Alcohol is a poison even in small doses,
Take care of the partiers with curious noses.
But you'll hear me proclaim ere my words fade from sight,
Have a safe Christmas and to all a good night.
Saturday, December 4, 2010
Fit to be Tied
Fit, spell, seizure, epilepsy, ictus are all terms that denote a seizure. Let's start with a definition. A seizure is a sudden neurological event caused by an abnormal excessive discharge of a group of neurons in the brain. The disease, epilepsy is recurrent seizures due to a chronic underlying process. Seizures are grossly divided into generalized and partial (focal).
Simple partial seizures do not lead to alterations in consciousness. The patient may have motor, sensory, automatic or psychic symptoms. Complex partial seizures include alteration in consciousness in addition to automatisms such as lip smacking, chewing, aimless walking or other complex motor activities.
Generalized seizures are either grand mal (tonic-clonic) or petit mal (absence). Have I ever mentioned that the French were the pioneers in neurology?
Grand mal seizures always present with a loss of consciousness and posture control. During the tonic phase there are marked contraction of muscles. Teeth clenching may lead to oral trauma and bleeding. The clonic phase of the seizure demonstrates rhythmic jerking of the body. There is usually a loss of control of the bladder and sometimes the bowels. A person having a grand mal seizure is not swallowing his tongue. One should not try and force anything into the patient's mouth. First aid is to remove any objects around the victim that they might cause injury and if possible to turn them onto their side.
Absence seizures are best described as a sudden brief impairment of consciousness without a loss of posture control. The typical petit mal seizure is 5-10 seconds of staring with minor motor twitching. The danger is that a petit mal seizure occurring while driving or performing any dangerous task could be disastrous.
Focal seizures involve only part on the body. Sometimes a single limb or side of the face, or more commonly a half of the body. Focal seizures are caused by anatomical abnormalities on the side of the brain opposite the side where the seizure activity is noted.
Some clonic movements may also be seen with many forms of syncope. Cardiac arrhythmias, vasovagal syncope, hyperventilation syncope may all show brief muscle twitching. In the ER psychogenic or pseudoseizures are part of the differential diagnosis in the seizure work up. Often patients with a true seizure disorder will have pseudoseizures. The lack of respiratory muscle involvement, the stylized movements and the lack of a postictal period of confusion and lethargy help to separate the psychogenic from the true seizure.
Seizures are often idiopathic, that is that there is no known cause. Genetics do play some role in idiopathic seizures. Tumors of the brain or metastatic tumors from other cancers, vascular anomalies such as AVM's (arteriovenous malformations), strokes and trauma to the brain are all anatomical causes of seizures. Many medications and abusable substances lower the seizure threshold and may lead to seizures. Isoniazid for tuberculosis, alkylating agents for chemotherapy, antimalarials (chloroquine and mefloquine), antipsychotics, antidepressants, alcohol, speed, cocaine, PCP, and methylphenidate are just some of drugs that may cause seizures.
In the patient with known epilepsy, a recurrent seizure work up will include an examination for any evidence of brain injury, infections, electrolyte abnormalities, and blood levels of the anticonvulsants that are prescribed for the patient. A drug and alcohol panel may also be done. Missed doses or simply stopping their medications are most often the cause of the recurrent seizure.
A first time seizure in an afebrile child or adult will lead to a more comprehensive work up. Besides blood and urine tests and a detailed history and physical exam, some type of imaging study will be performed. A CT or MRI of the head is part of the initial examination. An EEG will be done as soon as possible. Neurologists prefer that the patient not be started on an anticonvulsant until the EEG has been done. The ER doc must strongly admonish the patient that he or she is not to drive, operate machinery or engage in dangerous activities (scuba diving, climbing ladders, skiing, etc) until cleared by the neurologist. Seizures with fever especially in an adult may indicate a CNS infection such as meningitis or encephalitis and an LP will need to be performed.
Simple febrile seizures are a fairly common ER occurrence. In children from 3 months to 5 years, a seizure that is generalized, lasts less than 5 minutes and is accompanied by a fever is the usual presentation. The work up will depend on the individual patient's history and physical examination and height of the fever. About 80% of children who have a simple febrile seizure will not have any additional seizures. The EEG and use of anticonvulsants is rarely needed except for the 20% who return in the future with second or third febrile seizures. First aid as mentioned earlier is to protect the child from injury and to turn him on his side.
A newborn having a seizure, with or without fever, will be more aggressively evaluated with CT and LP almost always being part on the examination. Birth trauma and neonatal infection are the most common etiology of seizures in this patient population.
Status epilepticus is a life or death emergency in the patient with seizures. Status is the term used to describe a patient who has multiple seizure without a return to full consciousness or a patient who has continuous seizure activity. Untreated, status epilepticus will cause permanent injury to the brain or death. A recent patient of mine illustrates the difficulty in management of this condition.
The patient was man in his 60's who had had a hemorrhagic stroke in the past. He had a craniotomy to remove accumulated blood and was taking anticonvulsants. The injury to his brain had been on the left side. He presented to the ER with the paramedics and had been given IV lorazepam. This medication is a benzodiazepine and is a rapidly effective anticonvulsant. The patient was still having seizure activity involving the right side of his face and his right arm and leg. Blood tests and a CT did not show any obvious cause of his continued seizure activity. The patient was endotracheally entubated to protect his airway and multiple doses of ativan were given. He was given a loading dose of phenytoin, an additional anticonvulsant and paralytics to stop the motor activity. I arranged for urgent transfer to a tertiary care hospital as even when paralyzed the seizure activity of the brain could still be occurring. He needed continuous EEG monitoring. As he was about to be transferred I noticed a subtle twitching of his right eyelids. My parting shot was a loading dose on phenobarbital, a potent anticonvulsant.
Seizures are a frightening experience for the patient, their family and friends and even the bystanders who witness the ictus (from the Latin, meaning to strike). Historically, people with epilepsy were considered possessed. Exorcisms, trephinations (holes drilled into the skull) were perpetrated against these unfortunate patients. The psychic pronouncements of individuals with simple partial seizures may have been the basis for the oracles of mythology. As enlightened humans we should recognize that epilepsy in all its manifestations is diagnosable and treatable. There is no room in the 21st century for stigmatizing patients with epilepsy.
Knowledge leads to understanding.
Simple partial seizures do not lead to alterations in consciousness. The patient may have motor, sensory, automatic or psychic symptoms. Complex partial seizures include alteration in consciousness in addition to automatisms such as lip smacking, chewing, aimless walking or other complex motor activities.
Generalized seizures are either grand mal (tonic-clonic) or petit mal (absence). Have I ever mentioned that the French were the pioneers in neurology?
Grand mal seizures always present with a loss of consciousness and posture control. During the tonic phase there are marked contraction of muscles. Teeth clenching may lead to oral trauma and bleeding. The clonic phase of the seizure demonstrates rhythmic jerking of the body. There is usually a loss of control of the bladder and sometimes the bowels. A person having a grand mal seizure is not swallowing his tongue. One should not try and force anything into the patient's mouth. First aid is to remove any objects around the victim that they might cause injury and if possible to turn them onto their side.
Absence seizures are best described as a sudden brief impairment of consciousness without a loss of posture control. The typical petit mal seizure is 5-10 seconds of staring with minor motor twitching. The danger is that a petit mal seizure occurring while driving or performing any dangerous task could be disastrous.
Focal seizures involve only part on the body. Sometimes a single limb or side of the face, or more commonly a half of the body. Focal seizures are caused by anatomical abnormalities on the side of the brain opposite the side where the seizure activity is noted.
Some clonic movements may also be seen with many forms of syncope. Cardiac arrhythmias, vasovagal syncope, hyperventilation syncope may all show brief muscle twitching. In the ER psychogenic or pseudoseizures are part of the differential diagnosis in the seizure work up. Often patients with a true seizure disorder will have pseudoseizures. The lack of respiratory muscle involvement, the stylized movements and the lack of a postictal period of confusion and lethargy help to separate the psychogenic from the true seizure.
Seizures are often idiopathic, that is that there is no known cause. Genetics do play some role in idiopathic seizures. Tumors of the brain or metastatic tumors from other cancers, vascular anomalies such as AVM's (arteriovenous malformations), strokes and trauma to the brain are all anatomical causes of seizures. Many medications and abusable substances lower the seizure threshold and may lead to seizures. Isoniazid for tuberculosis, alkylating agents for chemotherapy, antimalarials (chloroquine and mefloquine), antipsychotics, antidepressants, alcohol, speed, cocaine, PCP, and methylphenidate are just some of drugs that may cause seizures.
In the patient with known epilepsy, a recurrent seizure work up will include an examination for any evidence of brain injury, infections, electrolyte abnormalities, and blood levels of the anticonvulsants that are prescribed for the patient. A drug and alcohol panel may also be done. Missed doses or simply stopping their medications are most often the cause of the recurrent seizure.
A first time seizure in an afebrile child or adult will lead to a more comprehensive work up. Besides blood and urine tests and a detailed history and physical exam, some type of imaging study will be performed. A CT or MRI of the head is part of the initial examination. An EEG will be done as soon as possible. Neurologists prefer that the patient not be started on an anticonvulsant until the EEG has been done. The ER doc must strongly admonish the patient that he or she is not to drive, operate machinery or engage in dangerous activities (scuba diving, climbing ladders, skiing, etc) until cleared by the neurologist. Seizures with fever especially in an adult may indicate a CNS infection such as meningitis or encephalitis and an LP will need to be performed.
Simple febrile seizures are a fairly common ER occurrence. In children from 3 months to 5 years, a seizure that is generalized, lasts less than 5 minutes and is accompanied by a fever is the usual presentation. The work up will depend on the individual patient's history and physical examination and height of the fever. About 80% of children who have a simple febrile seizure will not have any additional seizures. The EEG and use of anticonvulsants is rarely needed except for the 20% who return in the future with second or third febrile seizures. First aid as mentioned earlier is to protect the child from injury and to turn him on his side.
A newborn having a seizure, with or without fever, will be more aggressively evaluated with CT and LP almost always being part on the examination. Birth trauma and neonatal infection are the most common etiology of seizures in this patient population.
Status epilepticus is a life or death emergency in the patient with seizures. Status is the term used to describe a patient who has multiple seizure without a return to full consciousness or a patient who has continuous seizure activity. Untreated, status epilepticus will cause permanent injury to the brain or death. A recent patient of mine illustrates the difficulty in management of this condition.
The patient was man in his 60's who had had a hemorrhagic stroke in the past. He had a craniotomy to remove accumulated blood and was taking anticonvulsants. The injury to his brain had been on the left side. He presented to the ER with the paramedics and had been given IV lorazepam. This medication is a benzodiazepine and is a rapidly effective anticonvulsant. The patient was still having seizure activity involving the right side of his face and his right arm and leg. Blood tests and a CT did not show any obvious cause of his continued seizure activity. The patient was endotracheally entubated to protect his airway and multiple doses of ativan were given. He was given a loading dose of phenytoin, an additional anticonvulsant and paralytics to stop the motor activity. I arranged for urgent transfer to a tertiary care hospital as even when paralyzed the seizure activity of the brain could still be occurring. He needed continuous EEG monitoring. As he was about to be transferred I noticed a subtle twitching of his right eyelids. My parting shot was a loading dose on phenobarbital, a potent anticonvulsant.
Seizures are a frightening experience for the patient, their family and friends and even the bystanders who witness the ictus (from the Latin, meaning to strike). Historically, people with epilepsy were considered possessed. Exorcisms, trephinations (holes drilled into the skull) were perpetrated against these unfortunate patients. The psychic pronouncements of individuals with simple partial seizures may have been the basis for the oracles of mythology. As enlightened humans we should recognize that epilepsy in all its manifestations is diagnosable and treatable. There is no room in the 21st century for stigmatizing patients with epilepsy.
Knowledge leads to understanding.
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