Doc Talk

kids' hrad cases

According to research that was published by the American Academy of Pediatrics, emergency departments across the country are seeing more kids who have suffered a concussion or head injury. Even though 13% less kids are playing contact sports than 15 years ago, the number of kids with concussions has doubled. It wasn’t just high school athletes, but also kids from 8-13 who were also increasingly at risk.

The numbers are frightening but also need to be taken in context. Today’s awareness of the potential for significant long term complications of repeated concussions that are stacked closely in time, has made, athletes, parents and coaches want immediate medical evaluation of every potential head injury. This drives patients to the ER, where statistics capture their every visit. Often there is a push to perform a CT scan to insure no bleeding or bruising of the brain, even if the athlete is neurologically normal. A normal CT is followed by an equally strong push to allow the athlete to return to play.

The latest return to play guidelines stress that no player return immediately, repeat neurologic evaluation be performed and decisions be made days, not hours, later. The reason is pretty clear .While a CT can evaluate the brain’s structure, it is much harder and takes time and skill to assess its function. Many team doctors use computer testing, for example the IMPACT test program www.impacttest.com , to look for subtle changes in concentration and mood. Otcanhers rely on clinical judgment and neuropsychologic testing to decide who can play and who can’t.

This is a major change from a decade ago. Minor head injuries were evaluated on the sideline by a trainer and based on the prevailing wisdom of the time and supported by guidelines form the American Academy of Neurology, some athletes could return to the field of play almost immediately. Often kids weren’t seen until days later by their family physician or pediatrician and CT scan was not an automatic assumption.

While it is likely concussion rates are increasing because athletes are faster and stronger, even in elementary school, it may be that there has been a cultural shift. The more that parents and coaches read about pro athletes suffering from Alzheimer Disease at a young age because cumulative head injuries, the more they want to protect their kids from that potential. Football, baseball, basketball, soccer and hockey all have an increased risk of putting the head in the way of the action and increase the risk of brain injury.

Concussion can be and easy diagnosis. The athlete gets knocked out on the field, has some amnesia and is slow to get up and going. Concussions can also be subtle and hard to appreciate. The hit to the head may not be recognized wit hno immediate symptoms. Those may occur hours or days later and may be no more than a kid having a hard time concentrating in school, doing homework, having sleep issues or being more irritable at the dinner table. Impressive or not, a minor brain injury needs to be completely resolved before the player can return to play.

Treatment is time and rest, not only for the body but also for the brain. Video games, texting, computers may slow the recovery time and it may be the one time in a teenager’s life that they re encouraged to be a slug. But many high school seasons are short and parents and kids realize that being out two or three weeks may mean missing half a season. Frustration with brain healing may be an important part of the treatment that a doctor, team trainer and coach may offer.

There should be the expectation that emergency department visits will continue to rise for minor head injuries in children. Whether it’s from heads colliding playing ball or falling off a bike (please make your kid wear a helmet), the brain is a prime target for injury. Parents will take the cautious approach and bring them to a doctor. The next step is to appreciate that a normal brain on CT does not equal a normally functioning brain. It take time to heal and, as in most things medical, one cannot rush time.

when tests don't matter

As the great egg recall rolls out across the country, the salmonella scare continues to spread. Finding and destroying a half billion eggs sounds like it might wipe out the country’s egg supply but it is only a tiny fraction of the 80 billion eggs that are produced by US chickens. Few people will become infected, but that will not stop growing numbers to seek medical care to make certain that they are alright. The challenge for the care provider will be to meet the wants of the patient with the reality of what can be provided.

As with every doctor’s visit, the patient has certain expectations. Sometimes they are voiced but many times, they are unasked. A patient who comes in with a headache wants to be reassured that there isn’t a brain tumor present. The parent who has a child with abdominal pain wants to hear the words that appendicitis is not the cause. When people come to their doctor this week with vomiting and diarrhea, they want to be reassured that they are not potential victims of their morning breakfast of eggs over easy and salmonella infection.
Normally when we eat, the stomach acts like a mixing bowl, taking the food and turning it into a slurry. The watery mix passes through the small intestine where nutrients are absorbed into the body and is then delivered to the colon or large intestine. The colon acts like a sausage maker squeezing the stool along, allowing water to be absorbed back into the body and producing a solid bowel movement. When the stomach becomes irritated, it empties itself quickly by vomiting. Irritation of the colon causes it to squeeze down is a single spasm causing pain, and when it relaxes, the liquid stool rushes through the whole length of the colon with no time to allow water to leave. Out comes a liquid, diarrhea bowel movement.

The difficulty with the latest egg scare, is that symptoms of salmonella infection are exactly the same as any other cause of gastroenteritis (gastro=stomach + enter=intestine =itis=inflammation) or “stomach flu. And the symptoms of vomiting, diarrhea and crampy abdominal pain are usually caused by a virus.

The vast majority of people who have these complaints will not have salmonella. Sometimes it’s hard for patients to accept that the treatment is the same. Antibiotics are not used for salmonella, except in patients who have a compromised immune system, and the illness is allowed to run its course and usually resolves in a few days. If the symptoms are the same and the treatment is the same, there is little need to do any testing. Salmonella can be confirmed by cultures a stool sample, but for what purpose? The results will come back (positive or negative) just as the illness is resolving itself. How frustrating for the patient to be told that there is little to do except for supportive care and prevent dehydration.

When a test doesn’t matter, should it be done? Aside for the cost and messiness, there is little reason not to do stool cultures, except that if every patient demanded the testing labs across the country would be overwhelmed and other tests would be delayed. For other illnesses, there are consequences and potential side effects for unnecessary testing. A ”routine” CT scan of the head increases the radiation risk of cancer. Even the lowly blood test can cause bleeding or skin infection because of the needle stick.

As with most illnesses, prevention is the best treatment for salmonella. While the government and the food industry work on their recall, consumers can minimize their risk by cooking their eggs well. Thorough cooking kills the salmonella bacteria which means that over easy is out and the morning protein shake of raw eggs made famous by Rocky and Sylvester Stallone is definitely out.

And as for the next doctor’s visit, try to puts words to the purpose of the visit and ask the questions you want answered. While they can anticipate, sometimes they get it wrong and that can lead to an unhappy patient and unsatisfied care provider. Players on the same team need to communicate to get to where they want to go.

the danger that lurks

Looking after an injury isn’t good enough to satisfy the doctor’s inquisitive nature. There is always another question. If Eli Manning, the New York Giant’s quarterback, shows up with a forehead laceration, the worry is not necessarily how to make the scar look good, but whether the brain underneath has been damaged. Percy Harvin collapses at the Viking’s training camp complaining of a migraine and the next medical thought deals with the potential of sudden cardiac death. So it goes in medicine. Nothing is at it seems. There are dangers lurking beneath the surface and it’s the doc’s job to look for them.

Behind every injury, there is a story. An elderly patient who f breaks a hip may just have fallen, but why? Was it because they tripped on the dog or did they pass out when they fell? Are there other injuries in addition to the broken bone? And what medicines do they take that could have led to the fall? Or do they take blood thinners like Coumadin or Plavix that could lead cause future bleeding to occur? Why do they take those medications and will that underlying illness increase the risk of an anesthetic?

Specific injuries lead the doctor to look for complications and that means more questions. Bruised ribs makes warning lights go off looking for damage to underlying organs. While it makes sense to worry about the lung, the lower ribs also protect stuff in the abdomen, including the spleen that lies underneath the left diaphragm and the liver underneath the right. Trauma to the chest wall can lead to a few days of ICU observation for a fractured spleen.

An injured wrist may appear normal on X-ray but asking about pain and tenderness in the snuffbox, an area near the base of the thumb, may be the clue that the scaphoid is broken. It may take a couple weeks for the injury to show up on plain films but the treatment in a splint or cast needs to start right away.

Sewing up lacerations is fun but takes second place to making certain nothing other than the skin is cut. Hands are tough because of the tendons, nerves and arteries that run just beneath the skin. A good looking scar doesn’t help a missed nerve injury. Does the finger feel numb or tingling? Is there burning? Does it feel cold? And while the patient may say that everything is alright, the doctor needs to examine the area and be happy that the tendons are working and the nerve and blood supply are normal. Even with all that, before the skin is closed, the doc needs to look inside and find everything in working order.

It is too easy to ignore potential pitfalls. While common things are common, the basis of medical care is to look for those things that are not and questions are where the process begins. If the patient can’t answer them adequately, family and friends may be on the witness stand. A paramedic may be the person who provides the clue. The key is to ask…and ask again.

over the counter overdose

The news seems to be filled with celebrities who become overdose victims. Usually, it’s an accidental poisoning but sometimes it’s because of an intentional ingestion. While alcohol remains the most commonly misused drug and prescription pain medications like Vicodin and Oxycontin make headlines, it is the over-the-counter medications that are forgotten as perhaps most dangerous. The two that don’t get any respect are aspirin (salicylic acid) and Tylenol (acetaminophen).

Aspirin is perhaps nature’s most versatile drug. It’s a pain killer, an anti-inflammatory, controls fever and prevents blood clots. It’s available almost for free; generic aspirin sells for a penny a pill. It seems to be in every medicine cabinet and is there for the taking in an impulsive moment or when thoughts of self harm are overwhelming. Too much aspirin affects almost all the organs in the body. Commonly, it causes ringing in the ears, nausea and vomiting, changes in the acid-base balance in the body, pulmonary edema (fluid buildup in the lungs) and kidney failure. Most other organ systems in the body from the brain to the heart, liver and skin can be involved.

Making the diagnosis is easy if victims volunteer that they overdosed on the drug, otherwise it make take detective work looking at blood tests to make the diagnosis. Like most overdoses, treatment is supportive, making certain that basic body functions like breathing, heartbeat and circulation are maintained, but in significant overdoses, early dialysis may be needed to get rid of the drug from the body.

Tylenol is a nastier drug overdose. The drug is included in Many combination over the counter cold medications, as a stand-alone medication and comes in many user friendly forms (liquid, chewable, tablet, capsule, gelcap…are there more?) The bad news about Tylenol overdose is that there are no symptoms right away. Instead, the damage happens days later, causing the liver to fail. Once that happens, there are few long term treatment options other than liver transplant.

The good news is that Tylenol OD has an antidote, if given in time. Actually, it’s not an antidote in the true sense of the word. Tylenol gets metabolized by the liver into chemicals that causes liver cell death. A medication called mucomyst makes the liver deal with it and leaves the un-metabolized Tylenol hanging in the blood stream and lets the kidneys remove it from the body. The treatment needs to start immediately and can be given by mouth or intravenously.

Accidental overdoses happen and prevention is perhaps the most important treatment. Labels of over-the-counter medicines may not make exciting reading but the fine print will tell people what they might be putting in their body. Adding a cold medication to routine Tylenol and topping it off with a prescription pain killer like Vicodin or Lortab may be just too much Tylenol.

And when it comes to intentional drug overdose, medical treatment needs to happen side by side with psychiatric help and counseling. Perhaps one of the most important things we learn from celebrities is that even those who seemingly have everything do not live utopian lives and need help to cope with
the real world.

why heart attacks kill

My favorite team is anybody who plays the Yankees.

George Steinbrenner, the ship builder who also resurrected the New York Yankees empire died this morning of a heart attack. A myocardial infarction or heart attack doesn’t actually kill; the complications it causes are the killer.

The heart is a two stage electrical pump with heart muscle or myocaridium (myo=muscle + cardium=heart) being ordered to squeezing in a coordinated beat by an electrical signal that is automatically generated in atrium or collecting (upper) chamber of the heart. If heart muscle becomes irritated, short circuits in the electrical system can cause the ventricle or pumping (lower) chamber of the heart to malfunction. Sudden death may occur due to ventricular fibrillation where the heart fails to have a coordinated beat and sits there jiggling like a bowl of jello.

When a heart attack occurs, it is most often due to a clot that forms in one of the arteries that supplies heart muscle with blood. Without oxygen and nutrients, the muscle cells starve and start to ache causing chest pain or angina (sometimes it may be indigestion, arm and jaw ache or shortness of breath). If the clot is not treated, heart muscle starts to infarct or die. The amount of heart muscle at risk depends upon anatomy and what artery clots off. If it is a tiny branch artery, then just small amount of heart muscle is at risk; if it’s one of the three major arteries, then massive damage can occur. Unfortunately, the electrical system of the heart doesn’t particularly care if there is a small short circuit or a major power outage. Sudden death from a cardiac rhythm disturbance occurs because there is a focus of electrical irritability causing the ventricular fibrillation.

Size does matter in less common reasons to die of a heart attack. If a large amount of heart muscle is lost, the heart may be unable to generate enough squeeze to send blood to the rest of the body. No blood flow means no oxygen and no life. Large heart attacks can also cause the valves in the heart to malfunction, again disrupting blood flow to the body. And rarely, myocardial infarction cause also damaged muscle fibers to tear or rupture leading to sudden death.

The reason to understand the cause of death is to be able to do something about it. Getting emergency help for people suffering with chest pain is step one. The reason to call 911 instead of driving to the hospital is that ambulances carry monitors to look for abnormal heart rhythms and use medications to stabilize electrical activity and if necessary to use a defibrillator to treat sudden death. Step two is trying to re-establish blood supply to the area of the heart that is dying. In an acute myocardial infarction , where the EKG show a heart attack, the artery can be opened by emergency heart catheterization and angioplasty, perhaps with a stent, or the clot can be dissolved with drugs like TNK or TPA.

Step three really is step zero and that is prevention both as an individual and as a community. While one cannot control genetics and family history for heart disease, the goal is to decreasing risk by controlling blood pressure, high cholesterol and diabetes if they are present. Avoiding smoking is a given. And for community, it would be ideal if everybody could perform CPR and know how to use an AED (automatic external defibrillator) because even in the ideal world, people will still have heart attacks.

As with any celebrity who dies, the public will always be curious of the circumstances. But as it turns out, the final step in death is always the same. The heart stops beating and the lungs stop breathing. But for just today, perhaps my favorite team will wear the Yankee pinstripes.

Too drunk to drive

In the ER, the standard answer to whether a patient has been drinking alcohol is always the same…just a couple. Alternatively, the patient denies the question and demands to know why the doc wants the information and why it has any bearing on that particular hospital visit. The same scenario plays out on the streets when police pull over a drunk driver and ask them if they too have been drinking. Most of the time, these encounters are private affairs and are quickly forgotten, that is, unless you are the president of a large company with international recognition and the field sobriety is caught on tape. (http://link.brightcove.com/services/player/bcpid47552131001?bclid=0&bctid=104611093001)

Alcohol is a nasty drug that has social acceptance. It decreases inhibition, impairs judgment and slows reaction times and those are its positive effects. The negatives are that it is addictive. Alcohol exhibits tolerance and requires more of it to achieve the same effect. It also causes withdrawal symptoms when it is stopped after prolonged usage. The difficult issue with alcohol abuse is that while it damages the body of the person who drinks, it also has collateral damage. Drinking and driving has the ability to kill innocent bystanders and turns a car into a lethal weapon.

Not so long ago, surviving the drive home after a night out on the town was considered a badge of honor to be able to survive the gauntlet of police officers and sheriff’s deputies and to cheat death. Death doesn’t give up easily though. In 2008, there were11,773 people who died in the US in accidents involving a driver with a blood alcohol level greater than 0.08.

In truth 0.08 is not a magic number. It’s an arbitrary standard to define a minimum level of intoxication while driving a car. The number is lower if it’s an 18 wheeler and it’s zero if the vehicle is an airplane. Even the World Anti-Doping Agency, the organization that tries to control drug use in the Olympics, lists alcohol as a banned substance in sports involving guns and flying.

Intoxication occurs with the first drink that is consumed; even at levels as low as 0.02, a brain body disconnect can occur. Increasing the concentration of alcohol in the bloodstream will lead to incapacitation, where the person can no longer care for themselves. That number can vary widely depending on the drinking experience. Remember that because of tolerance a chronic alcohol may appear to function at levels above 0.40, which would be lethal to a novice drinker and may then go through withdrawal at 0.20. The number doesn’t matter; it’s the effect of the drug. But being awake does not equate to being sober or being able to drive a car, walk down the street or make reasonable decisions about who to go home with.

The sadness about the person in the video is that he was allowed to leave a large group of people, get in his car and start driving. Once the threshold of the first drink has been passed, the potential for an error in judgment exists. One drink leads to another and the damage may be done even with “just a couple” because of the generosity of a friendly bartender. It becomes a community responsibility to prevent the person from leaving a gathering while intoxicated. Friends don’t let friends drive dunk…even if he is the boss.

Breaking news

It doesn’t seem fair that a pro athlete can get hurt playing touch football in his backyard but survived unscathed while being hit by 300 pound linemen who are paid to inflict pain and suffering. Such is the fate of Carolina Panther, Steve Smith, who broke his arm. The injury required surgery to insert a metal plate to hold the bones in place but will also allow him to be healed in time for training camp.

Fracture, break, crack. It’s all the same. The integrity of the bone has been compromised and the issue becomes alignment and function. Are the bones in a position where they are going to heal in proper position and if a joint is involved, will the surface heals smoothly to prevent future arthritis?

Orthopedics has changed over time. Once upon a time bones were casted until they healed and it took forever to get the injured part moving again. Less than perfect alignments were acceptable, especially in older patients because life expectancy was short enough that the complications of arthritis and loss of range of motion didn’t have years to happen.

But times change. The movement to get the body moving more quickly has led to operating more and waiting less. Thin plates and screws made of metals like titanium are capable of holding bone fragments together so that immobilization times are decreased and patients can start rehabilitating their injuries sooner. Less cast time means less muscle loss and easier return of range of motion.
Injuries as diverse as collarbone or clavicle fractures in athletes (think Lance Armstrong) and the grandmother next door who broke her wrist have benefitted from more the more aggressive philosophy. Lance bets on his bike within days instead of the weeks required of normal healing. And grandma has her wrist plated so that the joint surface aligns and she can still swing a golf club well into her 80s and beyond

Better imaging with CT and MRI scans can show bones and joints in 3D, allowing the surgeon a chance to examine the inside workings of the body without cutting into it. Surgical repairs can be planned in advance and options explored before an incision is made.
Risks do exist for surgery. Older patients may have underlying health issues, from heart disease to diabetes that increase potential problems with anesthesia and healing. Infection is always a possibility when a cut is made into the skin. But there is always a balance in any medical decision. Risk - benefit analysis is not limited to picking stocks on Wall Street; every decision made to treat the human body has its upsides and downsides. Want to avoid an operation and be treated for three months in a cast? Remember the risk of blood clot formation in a limb that isn’t moving and pumping blood back to the heart.

While Mr. Smith’s injury isn’t fair, because of advances in orthopedics, he’ll be attending training camp field where the risk of getting hurt may be less than playing ball in his backyard.

Falling asleep or passing out?

The CBS headline was a little misleading. ”Patraeus Falls Ill During Senate Hearing”. In a sports reference, upon further review, General Patraeus briefly lost consciousness while sitting at a table. Words do make a difference. Being unconscious is not normal and though the General’s explanation may be correct that he had missed breakfast and was dehydrated, other potential diagnoses should be considered.

Being awake requires a few things. One cortex or half of the brain needs to be functioning plus the reticular activating system (the on/off switch in the brain stem) needs to be turned on. The heart has to be able to pump blood to the brain, there needs to be enough blood pressure to push the blood uphill to the head, the blood needs to contain oxygen and glucose and toxins that affect the brain can’t be present. When a person goes from fully awake to unresponsive, each requirement needs to be researched to decide the potential cause.

Sometimes it is easy. Medical students who pass out watching their first operation are the victims of a vasovagal episode where the noxious visual stimulus triggers the vagus nerve causing the heart rate to slow and blood vessels to dilate. Blood rushes to the feet instead of the head and the student passes out. The situation resolves spontaneously and the student wakens quickly and more than a little embarrassed. The same situation exists when an older person strains to urinate or have a bowel movement; the vagus kicks in and the person faints on the commode. Examples of other easy things to rule out are low blood sugar (the level can be measured at the patient’s side with a quick finger stick blood test) and dehydration, which should be evident on physical examination and changes in blood pressure and pulse rate. But easy does not equal not dangerous. Loss of blood can drop blood pressure, causing fainting and unconsciousness and patients with bleeding from their stomach or intestine can become gravely ill.

Sometimes it is harder. A patient is sitting at the breakfast table eating and suddenly they are slumped in their cereal for a minute or two and then recover. This is more like the General’s situation. The big question to answer is whether there was a heart rhythm abnormality that caused the heart to slow or stop beating for a few seconds causing syncope or loss of consciousness. It’s hard to sort out because most patients aren’t wearing a heart monitor and it may take detective work over days or months to try to find a cause and sometimes the search his fruitless. The second big question is whether it is a stroke involving blood flow to the brain stem where the on/off switch resides.

It’s the history that gives clues whether to follow the easy or hard pathway. The history leads to a few tests and all may be well…or not. The attention is placed on heart rate and rhythm because the danger lies there. A patient taking a diuretic or water pill for blood pressure control may have low potassium; a kidney dialysis patient may have too much. A patient taking medications that affect the heart rate may have too much medication on board and too slow of a heart rate to supply the brain with blood flow. Or the heart may be beating too quickly resulting in the same lack of blood flow to the brain.

The key to the diagnosis is allowing one to be made. Being unconscious even for a few seconds is not normal and deserves an evaluation. General Petraeus may be correct that he missed breakfast and passed out. Fortunately it happened at a senate hearing and not on the battlefield where missing a meal is routine.

Electrical storm

There aren’t very many freebies in medicine but they do exist and it may be that the seizure that Jeremy Shockey experienced may be just that. The New Orleans Saints player was in the locker room after a workout and became unresponsive and seized. Teammates described the frightening scene of shaking episode but trainers were able to assist until the seizure stopped and Mr. Shockey was transported to the hospital for care.

Seizures happen because the brain becomes irritated and an electrical storm occurs. Instead of normal connections occurring between the cells in the brain, an electrical storm occurs. This causes the brain to try to shut down because of the electrical surge. The muscle shaking occurs because the brain is ending out signals to every muscle group asking them to contract. Most seizures are self limiting and are followed by a post-ictal period, where the brain reboots and restarts all its programs just like a computer does when it has to restart.

Seizures are a common event and 4% of people will experience one in their lifetime. The potential to have a seizure depends upon the threshold of the brain to withstand excess electrical activity. In infants and children, high fevers can cause the threshold to lower and febrile seizures may occur. A blow to the head can cause an electrical spike causing a seizure and sometimes seizures just happen.

The patient needs evaluation to look for the reason for the seizure. Is there an infection? Are there electrolytes abnormalities in the blood? Is there a structural problem in the brain? Often there is no solid reason why the first seizure occurred and CT or MRI imaging of the brain and EEG (electroencephalogram) may be considered to look for a cause.

Most people get a freebie seizure before requiring medication but that doesn’t mean that the event should be ignored. The chance of having another seizure sometime in the future is about 20% and that may be why patients need to be seizure free for 3-6 months before being allowed to drive a car (time varies between states) , scuba dive, jump out of an airplane or other situations where a seizure could put the patient or others in danger.

Generalized seizures are frightening to witness. There is loss of consciousness, the body stiffens, arches and may shake, grunting sounds may be heard and it seems as if the person has been possessed. But most seizures stop themselves and the role of the good samaritan, bystander, friend or family is to protect the patient from himself:

• The first step is to take a deep breath and try to stay calm.
• Make certain that there is nothing nearby that can be struck by the patient.
• Don’t hold the patient down. A seizure is a violent and forceful event and bystander injury is a possibility.
• Do not put anything in the mouth. Seizing patients don’t swallow their tongue and usually are breathing adequately. Forcing open the jaw can break teeth or get fingers bitten.
• If the seizure lasts more than 3-5 minutes, call 911
• After the seizure stops, lay the person on their side and stay with them until they are awake or until help comes.

Mr. Shockey’s seizure may have a variety of explanations but he was fortunate that it was short in duration, occurred in a safe place and he returned to normal function relatively quickly. The goal for him and all patients who experience a seizure is to normal activity at work and at play. For some, like Shockey, work and play are the same thing and his expectation is to be on the football field and ready to defend a Super Bowl championship.

Risk taking

There are risks and then there are risks. Driving NASCAR fast comes with the risk of cars bumping, spinning out and flipping over. Add the risk of bleeding because your blood is thinned and it’s time to sit with the pit crew. Such is the story of Brian Vickers, a NASCAR driver on the sidelines because of pulmonary emboli or blood clots to the lung. When he gets to race again depends upon many things including why the blood clots happened in the first place.

Mr. Vickers is 26 years old and developed sharp chest pain when he took a breath; pleuritic chest pain in medical terms. Associated with a recently swollen leg, the diagnosis was probably made clinically by his physician. The leg swelled because of a blood clot or deep vein thrombosis. That clot broke off (now called an embolus) and traveled to the lung where it caused that part of the lung to stop working. Small blood clots present with shortness of breath and chest pain. Large clots can cause lung failure and death.

There are plenty of reasons to develop a deep vein thrombosis (DVT). Blood returns from the legs because muscles contract and milk blood back to the heart. Inactivity can cause blood to pool in the legs and clot while moving and walking circulates blood. Patients who are bedridden because of illness or injury are at risk and nursing care in the hospital deals with blood clot prevention. This includes patients with leg injuries who can’t walk. Often these patients are treated prophylactically with low dose blood thinners to prevent clot formation. Some patients have inborn errors of the clotting mechanism that cause blood to clot abnormally and form DVTs jus t because.

DVTs are inconvenient because they cause leg swelling and pain but it is a local problem. It’s only when that clot breaks off and travels that deadly occurs. The traveling clot (or embolus) travels in the veins that return blood to the right side of the heart and then gets pumped into the pulmonary arteries into the lung. The clot gets lodged in a segment of the artery. Just like any other area of the body that loses its blood supply, that part of the lung stops working causing shortness of breath and starts hurting. The large the clot load that damages the lung, the more lung function is lost and the sicker the patient can present.

The treatment for most blood clots is anti-coagulation or thinning the blood. This prevents further clot formation and decreases the risk that the clot that is already present will break off and embolize. But treatment isn’t good enough; the reason that the clot formed needs to be found to prevent further episodes and potentially prevent a life threatening disaster. Depending upon the situation, patients with DVTs have their blood thinned for three month and those with pulmonary emboli get treated for six months. If there is a genetic reason for the blood clot to form, treatment may be life long.
Every patient is different and treatment plans balance the risk of anti-coagulation with the risk of bleeding. These may include the risk falling or the interaction with other medications (antibiotics are a prime culprit). For a NASCAR driver who is always one turn away from a major wreck, the risk of bleeding is high and it is that reason why Mr. Vickers is on the sideline. His ability to return to competition depends upon why the clot happened. Was it because he sits is a car for hours on end driving in circles or is it because he has an inborn error of blood clotting? If it’s a blood clotting error, Mr. Vickers may need to take blood thinners forever and be unable to drive competitively again. Here’s hoping the clot happened because he was just sitting around too much.

Kobe's beef

Kobe Bryant should not be surprised that fluid accumulates in his knee since the body weeps when it is injured. Years of pounding up and down the basketball court has caused many of his joints to show some wear and tear and his coach revealed that Mr. Bryant had to have fluid removed from the knee during this past season. The presence of fluid presumes that an injury has occurred but does not determine the type or extent of that injury. Joint effusions are not normal and signal that there is inflammation ongoing within that joint.

Fluid on the knee or a joint effusion can occur from a variety of causes. Most commonly they occur because of injury to the ligaments or cartilage within the knee joint but can also be due to arthritis or other inflammatory causes. The initial evaluation that needs to happen depends upon what the story is and what the knee looks like. If the swelling occurred immediately after injury it is likely due to structural damage within the knee. A torn ACL will causes swelling within a few minutes, while a cartilage or meniscus tear may take many hours to cause fluid to accumulate. If there is not specific trauma and the knee is red and warm, the diagnosis would trend toward inflammation and gout (or pseudogout) would be a prime suspect. It’s important for the doctor to always keep infection in the back of their mind as a potential cause. An infection might occur because of a direct extension form a break in the skin of it could be delivered into the knee joint by the bloodstream from a remote source in the body.

Knee effusions hurt because the fluid stretches the capsule or lining structures of the knee causing pain. As well, the knee’s range of motion becomes limited because of hydraulics. The knee has its maximum space when it is flexed 15 degrees. Attempts to straighten the knee will cause significant pain since fluid cannot compress. Getting rid of the fluid to ease symptoms isn’t hard, the question always becomes why he fluid accumulated in the first place.

Diagnosis and treatment can go hand in hand. The knee joint is relatively easy to tap by inserting a long needle into the joint space. Withdrawing the fluid can relieve the pressure and pain and restore some range of motion. That fluid can then be sent for analysis to help with the diagnosis. Bloody fluid makes the diagnosis lean towards trauma, whether it is a torn ACL or a bony fracture. Clear fluid may not be so clear under the microscope and may be analyzed for infection or crystals. Uric acid crystals make the diagnosis of gout while the presence of calcium pyrophosphate crystals equals pseudogout.

The knee effusion is a sign that something is wrong in the knee and imaging (x-rays or MRI) may be appropriate. High paid athletes tend to get high tech tests while the real world relies more on clinical judgment. The drive to compete and playing through pain when there is a chance to win is another distinction between the real world and that of the elite athlete. For the LA Laker faithful, Mr. Bryant’s knee woes translate into the potential that he may not play effectively since removing the fluid does not fix the underlying problem. His motivation to win mirrors that of the fans’ but it is only Kobe’s body that is on the line.

the neck of the tiger

Neck pain and numbness in his hand has sent Tiger Woods to the sidelines and immediately into an MRI to find a diagnosis. That shortcut to imaging may the norm for an elite athlete but it isn’t routine for the rest of the world. Even for cervical radiculopathy, patience may be a virtue and potentially save a little money.

The spinal cord allows the brain to connect to the rest of the body, sending electronic messages that direct legs to walk, bodies to sit and hands to grasp. The return messages tell the brain about the world. Pain, touch, temperature, vibration and position are sensations that are transmitted from every part of the body. These messages are transmitted through nerves that enter and return to the spinal cord though spaces between the vertebral bodies that make up the neck and back. If the route where the nerve runs becomes narrow, the nerve can become inflamed causing pain and perhaps making it stop working. Often, there is just back that radiates along the course of the nerve, but numbness or electrical shooting pain can follow the nerve’s course. It’s like hitting the funny bone in your elbow, causing irritation to the ulnar nerve and causing difficulty making a fist, numbness of the little finger and pain at the elbow.

The nerves leaving the spinal cord can be inflamed for a variety of reasons including spasm of muscles that help support the vertebral bodies, bone spurs that form due to arthritis and excess wear on the joints between the vertebrae or injuries to the disc that help act as shock absorbers for the back. Regardless of the reason, the initial treatment tends to be less than aggressive. Diagnosis is usually made by history and physical examination and plain x-rays aren’t needed unless trauma was involved, like a fall or car wreck. Otherwise, rest, ice, anti-inflammatories like ibuprofen and pain medication may resolve the issue within days. If the pain persists, imaging may be suggested but physical therapy may be an option.

MRI or magnetic resonance imaging is the test of choice to look at the soft tissues of the back: the spinal cord, nerves, discs, muscles, tendons and cartilage that allow the body and brain to connect. It’s a lengthy test, requiring the patient to lie still for minutes on end and images need to be interpreted by a radiologist. Patients with metal in their body may be excluded, since the powerful magnetic force can literally rip metal out of the body. Playing “Alien” in real life is not wise.

The MRI results can help guide treatment if conservative therapy fails. There are different options available to treat a ruptured or bulging disc and surgery is only one. Therapy and injections are only two other options that are non surgical.

There are times when an MRI is emergently done but often it is a catastrophe that causes the emergency. Symptoms that point to a spinal cord at risk make tests and treatment happen quickly but the signs are not subtle. Inability to urinate or loss of bowel control, the acute inability to walk or use an arm or difficulty breathing are reasons to skip medication and therapy and run straight to MRI and potential surgery.

It is understandable that elite athletes whose timeframe to compete is limited by short careers jump the gun to get tests that “normal” people would forgo. They ask their bodies to do things that the rest of us cannot imagine and a minor injury can become major if not treated. Few of us can generate the force of a golf swing that a Tiger or Phil can and if we could, our bodies might break down, just like theirs have. The difference is that we can return to a restful workday but they have to walk to the first tee.

the worst headache

"Doctor, I have the worst headache of my life." Those words send up a warning when a doctor walks into a room to see the patient. The textbooks say that this symptom is one of the clues that the patient may be suffering from a subarachnoid hemorrhage (brain hemorrhage) from a leaking cerebral aneurysm. These words don't mean that a disaster is waiting to happen, but the red flag is waving. If those words are associated with a patient who is lying very still, complaining of a stiff neck, and has difficulty tolerating the lights in the room, this makes the suspicions rise even higher. Add vomiting and confusion as associated symptoms, and the sirens are going off in the doctor's head. Something bad is happening and time is critical.

There are four major blood vessels that supply the brain: two carotid arteries, right and left, that are located in the front of the neck and two vertebral arteries that are located in the back of the neck. They join together at the base of the brain forming the Circle of Willis, and from there smaller arteries deliver oxygen-rich blood to the far corners of the brain. There is a potential that one of the connecting points of those four major arteries can be weak.

Over time, the artery wall can start to bulge and form an aneurysm, a small sac-like bulge. One day, or maybe never, this aneurysm can leak and blood can escape into brain beneath the meninges (the membranes that line the brain). Blood is very irritating to tissue when it is outside blood vessels, and that leaked blood can cause the severe headaches and irritation of the meninges, causing a stiff neck. Usually, the first subarachnoid bleed isn't a killer. Instead it is a "sentinel" or warning headache and, if recognized, the aneurysm might be found and repaired. If it's missed, the next bleed can be catastrophic.

The diagnosis begins with the doctor's suspicion of a problem. Not all severe headaches are due to bleeding, strokes, or brain tumors, and it's the skill of the health-care provider to decide whether testing needs to be done. A CT scan of the head is the first test and the most likely test to find the diagnosis, but on occasion (less than 5%), the scan is normal. In this case, if the suspicion is still high, a lumbar puncture might need to be done.

Because the blood leaks into the space that connects the brain to the spinal canal containing cerebrospinal fluid (CSF), blood in the CSF can establish the diagnosis if the CT is normal. In some hospitals, CT angiography may replace lumbar puncture as the next step to be done.

Cerebral aneurysms are lethal if not treated. They are treated by a neurosurgeon or an interventional radiologist by clipping or removing the aneurysm to prevent the next bleed.

Sometimes, people go through their whole life with aneurysms and they never cause a problem. Why one person gets sick and another doesn't is always a tough question to answer. "It's the worst headache of my life" is black and white; either it's an aneurysm or it isn't. The answer as to who gets sick, and when a person gets sick, is a tough philosophical question and even tougher to answer at the bedside.

When you are the pharmacist

The downside to being a pro athlete is the scrutiny that it brings. One would think that the athlete would be extremely aware of what they put into their body since drug testing is so good at finding what shouldn't be there. When Edison Volquez took a medication prescribed by a Dominican physician to help start a family with his wife, he should have known that consequences would be far ranging, including as it turns out, a 50 game suspension. However, before we get too upset with Mr. Volquez, we should remember that this sin of taking unknown medications is all too common in the regular, non-sporting world. Consequences are not work suspension but instead, real medical complications that occasionally are life threatening.

In almost every grocery or drug store, shelves are filled with a variety of over the counter medications to treat almost any imaginable symptom. Some pills or liquids contain only one medication, while others have many drugs that have been mixed together to control multiple symptoms. Too often, taking a medicine with the best intentions to help a cough, stuffy nose or insomnia can cause significant side effects. Like any athlete, a patient should know the ins and outs of every medication that they put in their body, but in reality, it is sometimes too hard to decipher the chemical names and the complications of every drug on the shelf.

Two major culprits that hide in cold medications are phenylephrine and diphenhydramine or benadryl. The concept that over the counter medications are ultimately safe is put to the test with these two drugs. While they both have their place in the medicine cabinet, the fine print warnings are rarely read or adhered to. Phenylephrine works well to dry up secretions and make stuffiness and congestion of a cold easier to tolerate. Unfortunately, phenylephrine is closely related to adrenaline and can cause palpitations o rapid, irregular heartbeats and increase blood pressure. The warning label advises that patients with hypertension or heart disease avoid taking this drug but how many people bypass that warning. Phenylephrine hides in a variety of cold medications from Tylenol Cold to Walgreen generic cold remedies. Benadryl is just as sneaky. While it has great use as an antihistamine to treat allergic reactions and hives, if also has a potent side effect of causing drowsiness. The side effect is so common that it is the active ingredient in over the counter sleeping medications like Nytol and Sominex. Drowsy is good when getting ready for bed but not for people who drive or use heavy machinery. Driving under the influence applies just as much to medication as it does to alcohol.

Mr. Volquez was quoted as saying he must accept responsibility for his mistake and the use of a medication to treat a genuine medical problem even though it was banned by baseball. The same could be said for every person who takes an over the counter medication. The good intention can be overridden when something bad happens. Fortunately, there are resources available to decipher the chemicals that are present in over the counter medications and whether they might have unintended consequences and complications for a specific patient. Internet searches do wonders but the pharmacist is an underutilized resource when wandering the aisles of a drugstore. They have the ability to evaluate prescription medications, past medical history and other factors to decide whether one medication might be better than another and to balance upside benefit with downside risk.

While baseball can impose suspensions for as many games as it would like, the penalty pales in comparison to running a car off the road or developing symptoms from out of control high blood pressure. The bottom line for life and sports is that what gets into the body can affect performance and the responsibility begins before the pill is swallowed.

the excitement of the thyroid

Imagine playing baseball in front of thousands of cheering people, ready for the next pitch, heart pounding, mouth dry, the adrenalin rush of competition. Now imagine sitting in the locker room after the game or at home having dinner with family and friends and still experiencing those same symptoms. Imagine missing work because the heart pounding, dry mouth, sweaty palms was due to an overactive thyroid. Imagine the life of the New York Mets all star shortstop Jose Reyes who has just returned to play after being diagnosed with his thyroid issues in spring training.

The thyroid gland, located in the front of the neck can be thought of as the thermostat of the body, releasing hormones that help regulate heart rate, temperature and other body functions. Too much and the body speeds up with fast heart rate, sweating, diarrhea, irritability and weight loss. Too little thyroid hormone leads to symptoms like feeling cold, lethargy, constipation, weight gain and thinning hair. The thyroid doesn’t act alone with feedback loops to the pituitary gland in the brain telling it what to do, but sometimes things go wrong with the pituitary, the thyroid or both.

Usually, symptoms arise very slowly over time and the patient ignores or doesn’t realize that a problem exists. It may take significant thyroid enlargement (goiter) and a swelling in the throat to be the first sign that the thyroid may need some attention. Or it may be a relative or friend who notices that something isn’t quite right.

Diagnosis begins with talking to the patient, learning about the symptoms and examining the patient. Graves disease, where the thyroid enlarges can cause exophthalmos, a bulging of the eyes. Add a swollen thyroid gland in the neck and the diagnositic clues are easy to find. Too often, the diagnosis is thyroid problems is harder to make, but blood tests that can measure thyroid hormone levels in the body can help confirm that a thyroid problem exists. X-ray scans may be done to look at the thyroid gland in the neck, sometimes using radioactive dye to measure function and look for lumps or nodules.. If a thyroid nodule is found, tissue samples obtained by using a fine needle placed into the area are used to check for abnormal cells or cancer. Once the diagnosis is made, it’s on to treatment and control.

Low thyroid levels can be supplemented by thyroid replacement medications taken once a day as a pill. Too much is a different story. Beta blockers, medications that decrease the adrenalin response in the body, can be used to control the hyperthyroidism symptoms of increased metabolism. In addition, medications can be used to ablate or stop part, or all of the thyroid gland from functioning. On occasion, surgery is required to remove some or all of the gland.

Once thyroid function in the body is back to normal, regular blood tests are recommended to check thyroid hormone levels in the body, but often the patient knows when things are out of whack. Too jittery, too sleepy, fast or slow heart rate, feeling cold or hot all can point to the need for adjustment of the thyroid levels in the body. Thyroid disease often becomes a lifelong issue of monitoring and hormone control.

As with most things in medicine, the body functions well in a narrow range of normal. Get outside that range and symptoms happen. The excitement that is normal when an athlete steps on the field is special but loses its luster if it happens every moment of the day. Hopefully, Mr. Reyes can enjoy his excitement at the appropriate time.