Doc Talk

Chronic Traumatic Encephalopathy

nospam@example.com (Dr. Ben Wedro) — Mon, 14 May 2012 14:16:30 -0700

Getting your bell rung was once a badge of honor in sports. The ability to shake it off and not miss a play was accepted and routine. But it had been known for almost a hundred years that repeated hits to the head had long term consequences and “dementia pugilista” was the term used for a punch drunk old fighter who had been hit in the head one too many times. The realization was slow in coming that the same injury to the brain could occur in football players and that the most popular sport in the country could be a potential cause of psychiatric disturbances and early dementia.

A new term was born, chronic traumatic encephalopathy (CTE) that described a brain that had gradual degeneration in function because of repeated head injuries causing both concussions with symptoms and those that were asymptomatic. The symptoms of concussion had faded, but months and years later, new symptoms would occur. CTE symptoms start slowly and creep up on the patient. Initially, there may be concentration and memory issues with episodes of disorientation and confusion, dizziness and headache. It was as if the concussion symptom were starting to return even without a new head injury. Emotions would get labile and the patient could become aggressive and psychotic. As CTE progresses, behavior becomes even more erratic, with aggression and Parkinson-like symptoms. Finally, thought processes decrease even further into dementia with more Parkinson symptoms including speech and walking abnormalities. The symptoms are progressive and cannot be stopped.

The diagnosis of CTE is tough to make clinically. There are no bleeding or major abnormalities on CT scan and it appears to act like other diseases that attack brain function. It can be confirmed by autopsy and dissection of the brain but that doesn’t particularly help the patient. An abnormal protein called tau builds up in the brain and causes abnormal nerve fibers and cell tangles in the brain…and it looks different than an Alzheimer brain where loss of brain tissue was routinely seen.

Victims of CTE seem to may be more prone to death because of alcohol or drug overdose and suicide. The recent suicide deaths of NFL football players Junior Seau, Ray Easterling and Dave Duerson and NHL hockey players Derek Boogard, Wade Belak and Rick Rypien have brought the specter of CTE and chronic head injury to the front page but it isn’t just these athletes who may be at risk. The correlation between boxing and CTE should be expected because the goal of the sport is to inflict a concussion upon the opponent, but what about soccer players or non-athletes who are unlucky enough to sustained repeated concussions?

The CTE diagnosis is difficult since there is only supportive treatment and the consequences of the brain injury include early death. It would seem that prevention is the best and only option at the present time, but that may be difficult when society approves of the violence on the football field and boxing ring. Young athletes see themselves as invincible and indestructible. The pursuit of near term athletic glory overshadows the specter of long term disability, especially when the symptoms may be delayed by decades. People may have righteous indignation about the situation, but for now it stops on Saturday when they cheer for their alma mater’s colors and on Sunday when their favorite NFL team takes the field.

time to sew

nospam@example.com (Dr. Ben Wedro) — Mon, 07 May 2012 06:42:15 -0700

Wound care starts with history, learning what happened to damage the skin and whether other issues need to be addressed. A laceration that was caked with mud is more likely to get infected than one that happened slicing a tomato. A laceration that is 18 hours old is more likely to be infected than a wound that just occurred before walking into the doctor’s office. Where the cut is located on the body also matters. Some parts of the body have better blood supply than others and will heal faster. Scalps and face bleed a lot when they are cut but also heal faster. Shins have poorer blood supply and not only will take longer to heal and are also prone. Diabetic patients have poorer blood supply to their feet and it may take longer for foot lacerations to heal, if at all.

When the skin is violated, anything located underneath the wound is in danger of being damaged, including tendons, arteries and nerves. Knowing what’s underneath is important in knowing what injuries to look for. It isn’t god enough to sew up the skin and call it a day. The physical exam will make certain things work the way they are supposed to but examining needs to be confirmed by looking.

For the doctor, the fun stuff starts next. Armed with good tools, lots of light and a working knowledge of anatomy, the wound needs to be explored to the full extent of the wound and the process of wound repair begins.

• Step One: It all starts with making the wound numb; it’s cruel to hurt people, even if it’s for their own good. Local anesthetic can be injected into the area and depending upon the type of drug, its effects can last for many hours.
• Step Two: A light cleaning come next, usually with saline or salt water, to wash out the big particles of dirt and grime if they exist.
• Step Three: It’s important to look inside the laceration for potential bad things. If visual inspection confirms the physical exam and nothing bad is cut, then
• Step Four: more aggressive cleaning is needed. Perhaps the most important reason to care for wounds is to prevent infection and there is nothing better than washing. No soap is needed, plain irrigation or rinsing with saline is best. Soap damages cells and can prevent healing.
• Step Five: Time to suture. What type of suture that is used depends upon the situation and doctor preference but the purpose is to hold the skin edges together.

In fairness, once the wound is examined, explored and cleansed, sewing isn’t mandatory. Bringing the skin edges together will allow healing to occur more quickly and leave a better scar but if left alone most wounds will heal on their own. Sometimes, with dirty or old wounds it is best not to sew up the skin and lock in the potential for infection, but again, it’s the situation and the doctor’s experience that will make that decision, one patient at a time. Once the wound is repaired, the healing process starts and doesn’t stop when the stitches are removed. It takes months for the skin to finally repair itself and the final scar depends upon the type of injury, the doctor’s skill and the patient’s ability to heal.

In the operating room, planning where to cut and using a sharp thin scalpel, the plastic surgeon can make an incision almost undetectable. In the real world, people don’t plan their injuries, most places aren’t clean and the lacerations are jagged and uneven. It’s important to know that all cuts leave a scar, but it’s the doctor’s job to make it look good, not invisible but cosmetically appealing.

In the midst of the playoffs, when a hockey player gets cut, he only cares about getting back to the game. A quick trip to the locker room for temporary repairs can do the job, but those stitches can be removed and the real work done after the game. For the rest of us, one time getting fixed is enough.

ACL tears

nospam@example.com (Dr. Ben Wedro) — Sun, 29 Apr 2012 20:49:16 -0700

The knee is the largest joint in the body but it is held together by a ligament that is only an inch and a half long and less than a half inch wide. There is a lot expected of the anterior cruciate ligament (ACL) but the engineer who designed the knee probably didn’t expect 240 pound running backs to cut on a dime or 6 ½ foot power forwards to jump through the roof. About 100,000 people tear their ACLs every year but few do it on national television in the middle of the NBA playoffs. Every Chicago Bull fan held their breath and then sighed sadly as Derrick Rose, the league’s MVP, was taken off the court with a damaged knee that will take an operation and months of physical therapy to heal.

The knee is a hinge joint and is held together by four ligaments. The medical collateral and lateral collateral ligaments keep the knee from swinging side to side while the ACL and posterior cruciate prevent it from sliding front and back. The quads and hamstrings also provide support and together with the ligaments, allow the body to walk, jump, and squat and do all the things the legs are supposed to do. But the knee is vulnerable to injury since there is no bony protection for stability and it depends on those ligaments to keep it stable form the torque applied especially when pivoting and cutting. All of that is plenty to expect, especially from an ACL that has an area of only 2 square inches.

Damage to the knee can happen with no contact, usually from changing direction or landing from a jump when the knee is extended and the player tries to pivot at the same time. It can also happen when a player gets hit, but that is a high impact injury and it can also cause damage to the MCL and the medical meniscus or cartilage. This is the terrible triad of O’Donoghue, named after the Oklahoma orthopedic surgeon who repaired blown knees before the discovery of the arthroscope.

The diagnosis is relatively easy. The player can often hear of feel the ligament pop and there is intense pain. In sports, the trainer often rushes onto the court to examine the knee before it fills with blood and becomes so painful that the exam is fruitless. If the initial injury is ignored, the knee will continue to swell, give way and become increasing painful. For most athletes, the next diagnostic step is an MRI, to look at the anatomy, find the injury and sort out a treatment plan. But before any surgery is considered, one of the great advances in physical therapy has been the concept of pre-hab. When the knee becomes inflamed, the quads and hamstrings shut down and start to weaken. Pre-hap works on strengthening those muscles before the operation because there will be more muscle loss after the operation.

In athletes, the ACL has to be repaired to allow them to return to competition, otherwise an unstable knee will continue to buckle when placed under any stress. There are a variety of ways to fix the ACL but often a graft is done to replace the ligament by crafting a ‘new’ one one from another ligament from the hamstring or patellar tendons. In some cases, allografts, or pieces of tendon from a cadaver are used to replace the damaged ACL. Post op is when the patient has to really work at getting better and rehabbing the knee joint. The first few weeks are devoted to getting range of motion back to the knee while teaching the quadriceps muscle how to work again. Then there are the months of regaining strength and agility. No matter how technically good the surgeon, the success of the operation depends on the devotion and dedication of the patient to the almost year-long battle to restore the knee to where it was before the injury.

An ACL injury to an elite athlete is a disaster. It costs them a year of their competitive life with no guarantee that the knee will be physically the same. The next big challenge is mental and emotional. Will the athlete trust the knee enough to perform without the split second hesitation that is the difference between making a play and being a half step late. For Derrick Rose, his teammates and his fans, the answer to that challenge will be a year away and will depend upon a piece of tissue 1½ inches long and a ½ wide.

my aching back....and surgery

nospam@example.com (Dr. Ben Wedro) — Mon, 23 Apr 2012 09:10:06 -0700

There is never a good time to have back surgery but perhaps the best time is just before the nerves that leave the spinal cord stop working. A planned operation then becomes an urgent matter. And so goes the story for Dwight Howard of the Orlando Magic, whose season and Olympic team aspirations ended when he underwent surgery to repair a herniated disc in his low back. With his injury, Mr. Howard joins the two thirds of adults who have suffered with low back pain sometime in their lives and he becomes another worker whose low back pain and injury makes it the number one cause of work related injury.

Low back pain is a too common complaint and 80% of the time, the cause for the pain is not found. Usually the pain is muscular and gets better with ice, heat, ibuprofen and time. Sometimes the pain is due to inflammation of the nerve root that leaves the spinal cord to send and receive signals to the brain. Purposeful movement or motor nerve fibers send signals to the muscles to move while sensory nerve fibers return signals to the brain letting it know about things like pain, touch, pressure, temperature and position. If the space between the vertebra narrows in the back because of arthritis or a herniated disc (the shock absorber between two vertebrae), the nerve root can be pinched or irritated and cause symptoms.

There are 7 cervical, 12 thoracic and 5 lumbar vertebrae and the nerve roots are named for the space where they exit the back. Each nerve root is associated with a specific muscle and area of sensation in the body. Knowing the anatomy and matching it with muscle weakness and the area of numbness can help localize what nerve and therefore what part of the back isn’t working well. With a good history and physical exam, most people can have their diagnosis made clinically without need for x-ray or MRI. Basic treatment follows and most people have relief from their pain in a short period of time. Some people don’t respond and this is where we can learn from Mr. Howard’s injury.

Pro athletes tend to get many tests that are not offered to regular patients but that’s another column. Appreciate that Mr. Howard had a herniated disc causing his pain and he started the routine therapies that would be offered to everybody: rest, physical therapy, anti-inflammatory medications and steroid injections into the area surrounding the herniated disc. Urgent surgery was not recommended until his physical examination changed and he developed weakness in one of the muscles in his leg, a signal that the nerve was not just irritated, it was no longer working.

There are a few flashing lights that warn of impending disaster with low back pain and the need for urgent surgery. Pain is not one of them. It all has to do with the spinal cord and nerves that leave it. When the parts of the body that they control stop working, intervention needs to happen.
• If a patient loses control of their bowel or cannot urinate, this may be a sign of cauda equine syndrome, where the tail of the spinal cord becomes compressed and stops working. It may be due to arthritis and spinal stenosis that narrows the spinal canal or it might be trauma or a tumor that causes the narrowing. It is a true neurosurgical emergency because failure to fix the problem can leave the patient paralyzed.
• Another urgency occurs when there is painless weakness to the leg and the patient has difficulty lifting their leg against gravity. There may or may not be numbness but this is a sign that a nerve root is severely compromised.
• Extreme intractable pain is another indication for urgent surgery especially if a nerve root anesthetic fails to control the pain.

Without these situations and potential catastrophes, the common wisdom is that time and observation are important parts of the treatment plan for low back pain patients. This does not mean these patients should suffer but rather, their condition does not need an urgent referral for surgery. While surgeons do like to operate, they prefer to cut on people who have a high likelihood of getting positive results from their operation.

Dwight Howard taught us that knowing he had a herniated disc in his back, the first step to heal was rest and rehabilitation. Surgery was not the first step that he took towards recovery and it is unfortunate that he had to have any surgery at all. Now we get to wish him a speedy and full recovery.

how hot can the body get?

nospam@example.com (Dr. Ben Wedro) — Mon, 16 Apr 2012 14:15:40 -0700

The Boston Marathon is known for Heartbreak Hill, a climb late in the race where dreams are won or lost. This year, the race was decided the night before by the weatherman. Unseasonably warm weather put runners in danger of heat exhaustion and race organizers gave them the opportunity to sit this marathon out and try again next year. It’s not an easy decision to make. Runners have to qualify to enter Boston, they have dedicated months to training and then there is the expense and travel for those who have come from around the world to enjoy the experience of running 26.2 miles. But race officials did not want to replay the 2007 Chicago Marathon where hundreds of people were sickened by the heat, water was in short supply and the race was shut down.

The body generates significant amounts of heat with exercise and without the ability to cool itself, bad things can happen. Heat related illness described a spectrum of symptoms that begin with heart cramps that can progress to heat exhaustion with weakness, nausea and vomiting and finally ending up with heat stroke, a lethal situation where temperatures can spike and the victim becomes confused, the victim lapses into coma and potentially dies.

The body cools itself by sweating. Evaporation dissipates heat and for that to happen, three conditions need to be present. The body has to have enough water to make sweat. The air surrounding the body needs to have room to accept the sweat and there needs to be some air movement to help that sweat evaporate. Heat becomes an issue when the body dehydrates and there is no sweat production. Humidity is an issue if it is so high that there is no place for the sweat to go. Still air makes evaporation more difficult and it’s why ceilings fans work to cool a room.

The body has the ability to acclimate to heat but it takes about 10 days for that to happen. Exceedingly warm days early in the spring present a problem to athletes and construction workers where if the same temperature happened in the middle of the summer, it would be less of an issue. As it turns out, it’s all about the math.

• The average body at rest produces 100 kcal of heat per hour but with strenuous activity that can increase 10 fold to 1,000 kcal per hour.
• A non-acclimated person can dissipate about 580 kcal of heat per hour, plenty to take care of routine activity but not exercise or work in the heat of the day.
• An acclimated person can dissipate 1740 kcal of heat per hour, three times more.

Hydration is another important consideration. When the body is hot, it tries to cool itself and can manufacture 2-3 liters of sweat per hour, or about 4- 6 pounds of water that can be lost trying to cool the body.

It makes sense that the mainstays of treatment for heat exhaustion begin with stopping activity, removing the victim from the hot environment and beginning rehydration. Most patients with heat cramps and heat exhaustion do well but may need intravenous fluids because nausea and vomiting get in the way of being able to drink enough fluids to get the body back to normal.

Heat stroke is a different matter completely, since there is a high mortality when the cooling system of the body breaks down completely. Instead of sweaty skin, there is no sweat left to be made and the skin is hot and dry. Temperature regulation is completely lost in the body with fever spikes greater than 106°F. The diagnosis maker is the change in mental status of the patient. They may be confused, lethargic or unarousable, in coma. Heat stroke is a disaster and is often deadly.

Boston got it right this year, warning runners of the dangers of participating and giving incentives for them to walk away. 4,700 people chose not to run, but more than 22,000 toed the starting line. The runners paid attention and ran slower and smarter. The organizers had enough water on the course and enough medical personnel to make certain that those who started were able to be monitored. And for everybody involved, the race was a success…nobody died.

broken bodies and good luck

nospam@example.com (Dr. Ben Wedro) — Mon, 09 Apr 2012 06:32:28 -0700

“People will choose to blame their circumstances on fate or bad luck. Very few will admit it’s mainly the choices they have made.” Author unknown

Depending upon situation, the perception of luck is very different. The circumstances surrounding the motorcycle crash of Arkansas football coach, Bobby Petrino, provide an example that good and bad luck can exist at the same time for the same person in the same event. The Sparks notes version: while driving his motorcycle with his paramour as a passenger, Mr. Petrino crashes into the ditch. A passerby tries to call an ambulance but Mr. Petrino refuses. He is subsequently taken by private care to the emergency room where he is found to have a broken neck and four broken ribs. The bad luck is that marital indiscretions may exact a heavy cost to Mr. Petrino’s professional and personal life. The good luck is that he survived injuries that could have killed him or left him a quadriplegic.

It is bad luck that he sustained the injuries in the first place but there are significant complications that could have ended his like and it is fortunate that he survived his bad decision to refuse an ambulance. Multiple rib fractures are a sign of significant force applied to the chest and damage can occur to the organs that are protected by those ribs. Breathing can be compromised if the lung collapses or becomes bruised and just the pain of that many broken ribs can prevent the victim from taking deep breaths. Lower ribs protect the organs of the upper abdomen and their fracture can signal a damaged liver or spleen. Upper ribs protect the large blood vessels like the aorta and subclavian arteries that can be torn if enough energy is applied to the body with imminent death a real possibility. And of course, the heart sits in the middle of the chest and is at risk for injury.

When trauma patients go into shock, there are reversible life threatening causes that need to be considered and they are all in the chest. The major disasters include tension pneumothorax (a type of collapsed lung) pericardial tamponade (fluid that collects in the sac surrounding the heart and prevents it from beating), sucking chest wound (most often due to a laceration, stabbing or gunshot wound) and flail chest, where each rib is broken in more than one place and breathing is compromised. A patient who looks good initially can decompensate very quickly.

The brain is connected to the rest of the body by the spinal cord and it in turn is protected from the outside world by the spine. Unfortunately, the cervical spine, the bones in the neck, are at risk for breaking when the body gets thrown around at high speed. There is a reason that first responders, EMTs, paramedics and emergency room staff are careful in moving a trauma victim. If there is significant mechanism of injury to the body, the common mantra is that the neck is broken until it is proven not to be. If a vertebra in the neck is broken and the spinal cord is affected, the patient can become a quadriplegic if the neck is moved. A neurologically intact patient can be damaged if care is not taken to prevent that neck movement.

Not all broken necks involve the spinal cord. Many fractures are stable and need nothing more than a hard collar to act as a splint. Others are unstable and need surgery to repair. It’s not always possible to know in the field or the ER what might be happening to the neck or the rest of the back. The common wisdom is to immobilize the patient in a collar and backboard until the injuries can be sorted out. How tragic if an unstable neck fracture is missed and the patient goes from normal neurologic function to a wheelchair. Presuming the worst is not just an Eeyore mentality; it’s the right thing to do. And it is often difficult initially to assess , especially if the patient has a painful distracting injury…like broken ribs… that prevents them from appreciating their neck pain. Some trauma patients are kept in protective cervical collars for hours and days until the dust settles.

But back to Mr. Petrino. There are lessons to be learned from his good luck that allowed him to survive some significant bad medical decisions. Unless there is imminent disaster, think of exploding cars, drowning or a victim who isn’t breathing, it is best not to move a trauma patient. They can be warmed and comforted but a spinal cord injury should always be a concern. Trauma victims with chest pain or who can’t breathe deeply because of pain need medical attention and it should not be delayed. Paramedics have the skills and tools to perform with lifesaving procedures even before they arrive at the ER. Depending upon what part of the body is damaged, there can be associated life and limb threatening injuries that cannot be diagnosed in a passerby’s car.

In the United States, trauma remains the number one killer of people under the age of 45. While prevention is key, it is important to know what to do when an accident occurs. In so many ways, Bobby Petrino is an example what not to do.

“Luck never made a man wise.” Seneca, Letters to Lucilius

bell's palsy and the unasked question

nospam@example.com (Dr. Ben Wedro) — Mon, 02 Apr 2012 16:02:21 -0700

Bell’s Palsy is one of those diagnoses that defines the disconnect between physicians and patients. Imagine the thoughts that raced through Kim Mulkey’s mind when she looked in the mirror and saw that half her face was paralyzed. The Baylor womens’ basketball coach was diagnosed with the nerve irritation just before she left to coach her team at the national championship. Unless, they have had experience with Bell’s, most people don’t calmly survey their face, but instead move right into panic mode worrying about stroke or other brain disasters.

Bell’s palsy describes irritation of the 7th cranial nerve, the nerve that controls the face muscles and allows a smile, frown, a tight squeeze of the eye and other facial expressions. If the nerve stops working, the muscles it controls stop working as well. Bell’s is a peripheral neuropathy just like hitting your funny bone (actually the ulnar nerve) at the elbow and having your hand hurt and go numb. The body anatomy is described like a computer. Central problems involve the brain and spinal cord. Everything else is peripheral and affects the nerves after they have exited the central system and made their way to the far reaches of the body.

In the ER, Bell’s is an easy diagnosis and usually takes a minute or two at most to make. Often the nurses make the diagnosis as they place the patient in the room and the doctor has to work hard to keep an open mind. The facial droop is easily seen but because the way the face is wired, the key to the diagnosis is looking at the whole face. If the patient cannot wrinkle their forehead, then the diagnosis is Bell’s. If they can wrinkle it, the big concern is something bad happening centrally in the brain like stroke, bleeding or tumor. Common things are common and most often the diagnosis is Bell’s. The doctor makes the pronouncement, suggests treatment and leaves the room happy that all is well.

But all isn’t well with the patient, because they looked in the mirror and thought stroke. Without hearing the actual magic words like stroke, brain bleeding or tumor, the patient might leave the doctors still fearful that some disaster is percolating. The same disconnect happens with other complaints and unless the doctor can anticipate the patient’s unasked question, their needs won’t be met. The diagnosis may be fine but there is something missing with the visit. Some unasked questions are easy. Abdominal pain equals appendicitis. Chest pain equals heart attack but never mind that other killer diagnoses can also present with chest pain. Leg swelling equals blood clot. In most unplanned visits to the doctor, the patient fears some disaster diagnosis whose name needs to be spoken before the visit can be called a success.

Sometimes the unasked question is so specific to the patient’s situation that the permission must be given to actually ask the question. The worry might stem from a relative who had a catastrophic illness that began with a benign complaint. There may be a previous experience where the diagnosis was delayed or missed and may cause longstanding fear and distrust. Regardless of the situation, both patient and doctor need to be on the same page.

While the playbook needs o be the same, the patient does not get the automatic right to demand tests or treatments that would not necessarily be beneficial. Not all headaches need CT scans or MRIs and not all chest pain needs a heart catheterization. Sometimes, though, the battles aren’t worth fighting from the doctor’s perspective and it may be easier to give in to technology instead of standing firm with a diagnosis made on clinical grounds. That should be the exception. Patients need to be involved in decision making and deserve to understand what the doctor is thinking and how the diagnosis came to be made… with or without technology.

Back to Ms. Mulkey and her paralyzed face. When she left her doctor’s office, she knew that her face didn’t move because of a peripheral neuropathy. Hopefully she was also told what wasn’t going on and perhaps she asked the questions that are often left unasked.

when dead isn't

nospam@example.com (Dr. Ben Wedro) — Mon, 26 Mar 2012 10:37:24 -0700

78 minutes is a long time to be dead. Thousands of people witnessed Fabrice Muamba collapse dead in the middle of a soccer game. Paramedics rushed to his side and immediately started CPR and for 78 minutes they pressed on his chest and breathed for him on the field, in the ambulance and in the ER. Muamba’s heart was in ventricular fibrillation, a chaotic electrical rhythm where heart muscle cells are bombarded by electrical signals and there is no coordinated contraction to pump blood to the brain and rest of the body. The best chance of surviving is being shocked. 14 times, Muamba’s heart was shocked with no change in the electrical chaos, but with the fifteenth shock, the electrical signals aligned, the muscles squeezed together and Muamba’s heart started to beat.

Dead is a fluid concept. Dead is official when a police officer, medical examiner, coroner or physician declares the patient dead. This is often a frightening prospect for medical students and interns who fear that a patient declared dead will start breathing again. In ancient societies, families watch over a dead relative for days to make certain death was permanent. And then there is brain death, where the body functions normally from the neck down but all brain function has stopped. This different philosophy of death is relatively recent and most important to those in the transplant medicine including the organ procurement personnel, the transplant surgeon, those on the organ waiting list and of course, the family of the brain dead patient. Every other cause of dead occurs when the patient’s heart stops beating.

Cardiac arrest is different than a heart attack or myocardial infarction. With an MI, one of the blood vessels blocks off and the part of the heart muscle that it supplies dies. Heart muscle that loses its blood supply also gets very irritable and can cause the onset of ventricular fibrillation or cardiac arrest. The heart stops beating and the patient dies.

The heart can stop beating in different ways. It can stop with asystole where no electrical activity can be detected and little can be done to restart it. Even pacemakers tend to fail. The heart can stop because of pulseless electrical activity, where the electrical system works but it is disconnected from the heart muscle and no beat is generated. The treatment for this is looking for the underlying problem and fixing it. The problems tend to be bad like shock, collapse of the lung, buildup of fluid in the sac that surrounds the heart, very low body temperature, poisoning and abnormal potassium levels. Survival is rare. The best hope of surviving dead is having ventricular fibrillation since defibrillation (AED, everybody clear…shock) can change electrical chaos into a normal heart beat. And all V fib is not created equal. Coarse V Fib has lots of electrical activity and perhaps is more easily shockable while fine V Fib has less and isn’t.

For Muamba, the big question is why CPR was continued for 78 minutes and not stopped well before the 15th shock. Sometimes, shocks convert the heart into a beating rhythm but the effect doesn’t last but for a minute or two and V Fib returns. The temporary success spurs hope that another minute of two might yield success. Sometimes, it’s the patient. When an infant or child arrives in cardiac arrest, paramedics, doctors and nurses spend forever hoping to make dead go away. Kids who die cut to close to everybody’s heart and nobody wants to stop trying.

After 78 minutes, a strong heartbeat, a normal blood pressure and spontaneous breathing. Many hours later, the docs allow him to waken, remove the ventilator and watch while he opens his eyes, recognizes family and asks about his son. Dead is a fluid concept. Sometimes it ends with a miracle.

sudden death

nospam@example.com (Dr. Ben Wedro) — Mon, 19 Mar 2012 09:07:12 -0700

For most fans, sudden death is part of the game that is settled on the field; next score wins. In medicine, sudden death occurs when the heart short circuits, stops beating and causes unexpected collapse and death. This weekend, during a soccer match in England, the medical term played out in front of a packed stadium. Spectators watched as Fabrice Muamba collapsed and then witnessed paramedics began CPR and attempted to restart his heart with an AED.

Mr. Muamba wasn‘t as fortunate as some with sudden cardiac death where the AED recognizes the fatal rhythm, ventricular fibrillation, and delivers an electric shock and restarts the heart’s ability to beat. Muamba’s heart didn’t start right away and it took two hours of work in the hospital for a spontaneous heart beat to return. Medications were likely used to help restart the heart while paramedics, nurses CPR was continued, trying to keep blood circulating to his brain and organs. The final result of this sudden death won’t be known for some time. It only counts as a win if Mr. Muamba leaves the hospital as a person, not as a body.

Two hours is a long time to continue CPR but heroic efforts are often performed on infants, children and young adults because there is potential for a save. They usually have normal heart muscle but some glitch has caused the electrical system to fail. In babies, that glitch is usually a breathing complication that decreases oxygen supply to the heart muscles and in young adults it may be spontaneous onset of ventricular fibrillation where the electrical system short circuits. In older patients, the heart isn’t as resilient and the longer the CPR, the less likely that a spontaneous heart beat will return.

In sudden cardiac death the ventricle, or lower pumping chamber of the heart, develops a disorganized rhythm called fibrillation. The electrical impulses aren’t occurring at the same time and each heart muscle fiber contracts at a different time. The ventricle muscle isn’t coordinated and is unable to generate a squeeze to push blood out to the body. This is different than the commonly seen and not life threatening atrial fibrillation, where the upper chambers of the heart lack coordination but this does not stop the heart for circulating blood to the body (A fib has its own complication though and should not be ignored).

With prolonged CPR, there may be some minor victories where the heart restarts. A pulse can be felt, but is there a blood pressure. What is the rhythm on the monitor and is it one that can sustain itself or will it degenerate into something that can’t produce a pulse. This is a critical time for the resuscitated heart and the electrical rhythm can change quickly, literally second by second. And if the pulse goes away, regardless of what the monitor shows, CPR needs to start again. A little success spurs the team to try harder and longer and hope that the next round of drugs or the next shock will work…and sometimes it does.

If the cause of sudden death was ventricular fibrillation, then an implantable defibrillator may be the next step. It’s about the size of a pacemaker and is placed the same way in a small skin pocket in the chest wall. If another episode of ventricular fibrillation is detected, it can fire immediately and hopefully return the heart to a normal electrical state. The device also allows patients to return to a normal life and even an athletic one. Medtronics, a company that makes defibrillators, is also a sponsor of the Twin Cities Marathon and their foundation honors people who have returned to running (http://www.medtronic.com/2011globalheroes/our_heroes.html)

Victory in the ER is only one battle and many more need to be fought before the war can be won. The patient needs to be cooled since studies suggest that lower body temperature allows some increased brain recovery. The patient needs to wake up enough to breathe on their own and then, if they are fortunate, they regain consciousness and are able to return to normal like. Mr. Muamba has survived the first battle. His heartbeat has been restored. We hope that he is able to win in sudden death.

tiger's achilles heel...

nospam@example.com (Dr. Ben Wedro) — Mon, 12 Mar 2012 16:40:48 -0700

The image of Tiger Woods limping off the golf course is a reminder that pro athletes who have access to the best care still can have their bodies fail in the middle of competition. Conceding to an opponent is humbling but admitting defeat to one’s own body is another story completely. As it turns out, Woods’ Achilles heel at the World Golf Championship was his Achilles tendon and it looks like his body has read the injury textbook.

The Achilles tendon attaches the two calf muscles, the gastrocnemius and soleus to the back of the heel or calcaneus. Those muscles not only are responsible for walking, by flexing the ankle and moving the mid foot, but they also span the knee joint and help flex the knee. The tendon is the longest and thickest in the body and is prone to injury. Experiments show that when running, forces greater than 10 times body weight can be measured within the tendon. It is not unexpected that tendon inflammation (tendinitis) can occur when activity increases dramatically or body mechanics are wrong. It doesn’t help that there is a design flaw in the tendon. Because there is marked decrease in the blood supply to the lower part of the tendon, just a couple inches above where it inserts into the heel, this area is prone to injury (it’s also known as the watershed area of the tendon).

The usual suspects for the cause of Achilles tendinitis include overuse and often a quick increase in the length and intensity of an activity, poor shoes and problems with anatomy. Tight muscles that are asked to quickly contract with movement put stress on the tendon as it tries to stretch from the muscle belly to the bony attachment. Sometimes the tendon is injured and sometimes it’s the muscle itself. A strain describes a tear in the fibers that make up a muscle or tendon and small tears may be the beginning of the inflammation response that progresses to Achilles tendinitis.

When the Achilles becomes inflamed and irritated, pain develops at the watershed area, and is usually worse first thing in the morning after a period of immobility. As the area warms up, the pain can get a little better but activities that require pushing off with the foot, like walking, running, or twisting with a golf swing, will cause significant increase in the pain. Even the most strong-willed athlete may not be able to overcome the body’s want for self-preservation and a limp will develop to protect the inflamed area. The Achilles tendon area is located just beneath the skin in the back of the ankle and the swelling can not only be easily felt but it can often be seen. X-rays tend not to be helpful and the diagnosis is often made by the patient before the first doctor’s visit.

Achilles tendinitis has a good news/bad news prognosis. The good news is that basic treatment with ice, rest, ibuprofen and good shoe orthotics are helpful. Add gentle stretching, muscle strengthening exercises and physical therapy and the inflammation will resolve. The bad news is that it might take 3-6 months. Steroid injections tend not to work and have the risk of causing a tendon rupture. Platelet rich plasma injection therapy also does not seem to have a role. If the symptoms last more than six months, surgery is a potential option but recovery time is more than a year and 20-30% of patients have residual pain.

Mr. Woods’ Achilles woes and his recovery will be followed by his fans in the golf world, hoping that he can recover from this injury like he recovers from an errant drive that puts his ball in the rough. Miracle shots on the golf course have become part of his legend but unfortunately, his body follows the laws of physiology and healing cannot be rushed. Returning too early will potentially weaken the tendon to the point that it risks rupture and the certainty of surgery. As with many things in life, time invested early pays dividends long term.

On a related note, patients who have Achilles tendon inflammation are at risk for spontaneous tendon rupture if they are prescribed a common antibiotic in the floxin family (Cipro, Levaquin or Avelox).

broken faces

nospam@example.com (Dr. Ben Wedro) — Mon, 05 Mar 2012 16:15:25 -0700

Baseball is supposed to be a non-contact sport but when a ball is travelling close to 100 miles per hour, it’s sometimes tough to get out of the way. This is especially true, when the ball ricochets off the bat and there’s no time to blink. When A.J. Burnett of the Pirates tried to bunt the ball, it caromed up into his face and he was left with an orbital fracture that needed surgery to fix. Fortunately, it was the bone that got hurt and not the eye that it protected.

The eye socket is made up of seven different bones that provide protection to the eye itself and the other structures within the orbit. Surrounding the globe, muscles attach to bone so that the eye can swivel. In the back of the orbit, the optic nerve is the cable that collects information from the retina and runs directly to the brain delivering the sense of sight. Bad things can happen when the orbit gets hit and it’s important to sort out a sight threatening emergency from other injuries that can be assessed and treated at a more leisurely pace.

When the ball hit his eye, Mr. Burnett likely sustained a blowout fracture of the inferior orbital rim. The round globe of the eye is compressible and since it sits in an orbit that is shaped like a cone, anything that drives the globe back ward can cause the orbital bones to break, crack or fracture (all the words mean the same thing). The thinnest bone of the orbit forms the inferior orbital rim. It is part of the maxilla or cheek bone and helps support the eye from below and it is the most often bone to fail. While this is a painful injury, there are more important things to worry about.

The first order of business is to make certain that the eye works. Even though the eyelids may swell shut, they can be pried open to check vision. Can the patient see normally? If not, can they count fingers or see light? Or is there total blackness? Major vision loss is a true emergency and has to be sorted out relatively quickly. Injury assessment follows how light flows through the eye to get to the brain. The injury can be due to damage to the front of the eye, like a hyphema or collection of blood in the space between the cornea and the iris. There may be bleeding in the globe or the globe can be ruptured. Blood prevents light from travelling from the outside world and landing on the retina that lines the inner surface of the globe. A retina injury can prevent light from being received and damage to the optic nerve can prevent signals moving from the eye to the brain for interpretation.

If the vision is alright, then it’s time to check out the rest of the eye. Does the eye move normally? And does it move together with the other eye? If not, the patient may complain of double vision. Are there scratches on the cornea or superficial covering of the eye? Did the injury cause the pressure within the eye to increase (this is called glaucoma}. Broken bones hurt and palpating or touching them can help determine the location of the injury. There is a trick to help sort out inferior orbital rim injury. Numbness of the cheek or the upper teeth may indicate a fracture, since the inferior orbital nerve runs in a small groove beneath the eye and it turns off when irritated.

In a blowout fracture, the inferior orbital rim breaks and some of the fat that supports the eye and perhaps a bit of one of the muscles of the orbit get trapped in fractured spot. When the patient looks upward, the good eye moves but the injured eye cannot and the patient complains of double vision. If there is suspicion of a fracture, plain x-rays may be taken, but facial bone CT scan may better be able to show the anatomy and any other associated injury.

As long as the eye itself works, the decision to operate can be delayed. The ENT or plastic surgeon won’t be in a rush, often waiting for the swelling to decrease so that they can better plan their approach to injury repair. Meanwhile, routine icing and elevating the head of the bed will help decrease the swelling. The big instruction reminds the patient not to blow their nose. Since the inferior orbital rim is also the roof of the maxillary sinus, there can be an air leak into the orbit that blowing a nose can make worse and force air where it doesn’t belong.

Mr. Burnett’s return to work will take a little longer than usual. Aside from the month it will take to recover from surgery, he will need to spend more time getting back in shape as an elite athlete. Running, jumping and dodging 100 mph fastballs are not recommended activities immediately after the operation. In that regard, fractures are like baseball games. A baseball game takes nine innings to finish, no matter what the clock says. Fractures can also just take their own sweet time.

baseball and medical decision making

nospam@example.com (Dr. Ben Wedro) — Mon, 27 Feb 2012 18:19:37 -0700

The pilgrimage to Arizona and Florida has begun as pitchers and catchers have reported and spring training is under way. Perhaps more than in any other sport, decision making in baseball mirrors the medical thought process. Baseball revels in the notion that past performance can predict the future and statistics seem to matter. Beyond batting average, runs batted in and earned run average, every situation seems to have been documented so that one can look back and see how well a right handed hitter swung the bat against a left handed pitcher with men in scoring position. From ordering tests that may not be necessary to injecting drugs that could be a lifesaver, medical care has come a long way from being based on intuition and anecdote.

Twenty five years ago, a CT scanner was a rare and expensive machine. The decision to order a head scan to look for bleeding in the brain was a big deal. But the technology spread quickly to almost every hospital and many walk in clinics and doctors’ offices. More scans were ordered and perhaps patients were getting tests and extra radiation that they didn’t need. With too many normal tests being down for relatively minor head bumps (remembering that the scan was supposed to look for bleeding), researchers using statistical analysis were able to develop rules and guidelines that doctors could rely upon to reassure a patient that nothing bad was going on when they hit their head.

The CT rules are pretty common sense. A patient needed a CT scan of the head if they were not completely awake within 2 hours after injury, there was evidence of a depressed skull fracture or basilar skull fracture, there were two or more episodes of vomiting, there was greater than 30 minutes of amnesia, there was a dangerous mechanism like getting hit by a care or falling down many stairs and if they were older than 65.

However, the guidelines needed some interpretation. While a CT scan wasn’t necessary, there was still the possibility that a tiny amount of bleeding could be present in the brain but it would have no consequences and wouldn’t need any intervention or operation…that is, unless the patient was on a blood thinner like Coumadin, Pradaxa or heparin. Then, there were no rules. Not needing a CT scan also meant that the patient didn’t need to be wakened routinely through the night. It also did not mean that complications of concussion (for example, headache, and difficulty concentrating and sleeping) were not a possibility.

Bleeding in the brain is always a big deal and it is a major complication of using TPA, the clot buster drug to try to treat and reverse stroke symptoms. There are rules and statistics for TPA use as well. If used in the appropriate patient, the success rate in reversing stroke symptoms is about 33% but even using it wisely, there is a bleeding potential of 6%. The key is to find the right situation that minimizes bleeding and maximizes potential success. The major limitation to the use of TPA is time. The longer that brain tissue has been deprived of blood supply, the greater the chance that bleeding will be a complication. Three hours is the magic number from onset of symptoms to when the risk of bleeding becomes unacceptable (recently, that number has been increased to 4 ½ hours in some patients but there is still some controversy). In those three hours, the patient or their family has to recognize that a stroke has occurred, get to the hospital, have the diagnosis of stroke made, blood tests and CT scans done, the drug mixed and administered. The major stumbling block is the delay in getting to the hospital. Patients always hope that their symptoms resolve and by waiting, the treatment window sometimes slams shut.

Sometimes statistics are ignored only because the risk/reward leans strongly to the reward side of the equation. The reason most lacerations are sutured is too speed healing and achieve a better cosmetic result. The longer a cut is left open, the higher the potential risk of infection. Some research suggests that the infection rate spikes at 6-12 hours but it’s the location of the laceration that makes the difference. An old wound on the leg could be cleaned out well and left to heal on its own but the same cut on the face might be sewn shut because the risk of cosmetic deformity would outweigh the infection risk.

And then there’s the 800 pound gorilla in the room. When a patient presents with chest pain, statistics are hard to come by to decide whose story leans more towards the pain being angina and a potential heart attack disaster and who might have esophagus inflammation and heartburn. It may be the art of the history, the asking questions to understand the quality of pain and learning about the patient’s risk factors of high blood pressure, high cholesterol, smoking, diabetes and family history that might sway the doctor to worry more about the heart. It might be the art of the physical examination that finds an abnormal heart sound that leans towards angina or an early rash that could diagnose shingles. It might be the art of reading the EKG or of ordering and interpreting blood tests appropriately. Who needs hospital admission, who needs what test and who gets to go home depends upon skill, experience and intuition.

Players and managers often have gut feelings that motivate their decision making on the playing field. When they don’t follow the book, the downside is perhaps a lost game. In medicine, guidelines provide direction for patient care. Ignoring them may be appropriate but being cavalier may have more deadly consequences than a strike out. The art and science of medicine blend because every patient visit is unique and a single cookbook recipe will not fit every situation. The good doctor knows when to follow the guidelines and when to recommend that they be bent but bending should be the exception.

the scouting combine...medical style

nospam@example.com (Dr. Ben Wedro) — Mon, 20 Feb 2012 17:21:44 -0700

In the middle of February when pro basketball, hockey and golf are in full swing, it will be the NFL scouting combine that will make headlines. The decisions made by coaches and general managers about the athletic potential of college players may affect the future of their teams for years to come. Who knew that the same courtship is playing out in teaching hospitals around the country. Medical students have sent out applications in hopes of finding a coveted spot to pursue their residency training and now it’s interview time so that residency directors can put a face and personality to the credentials in the application.

It takes a long time to be able to hang a shingle and start caring for patients. After an undergraduate college degree, there is four years of medical school and then comes residency training. For primary care like family practice, pediatrics and internal medicine, it’s three years of post-graduate but that can extend to seven years or more for some specialties like cardiothoracic or neurosurgery. In medical school, students spend a few weeks rotating through each specialty, not only learning the medicine, but hopefully finding a passion.

While the students try to impress, residency directors hope that the students they recruit will fit well into their training programs. Not only do they have to be bright, (most are, they made it through medical school) but also have a caring spirit, a team mentality and willingness to fit into that particular hospital’s culture. A bad fit can cause grief that may last many years. When next year arrives and a new class comes to interview, meeting an unhappy resident can poison recruiting for a long while.

There is a third group that has skin in the recruiting game and that’s the local community. It seems that residents grow to like the area where they spend years in training. They develop relationships, have kids, join churches, synagogue and mosques and become part of the community. That makes it hard to leave if an opportunity to practice locally makes itself available. Newly graduated medical students who move to town to complete a residency program, may be the same doctors who will look after generations of people in the surrounding area.

Just like the NFL, the medical student visit isn’t the end of the recruiting dance. Once football teams have decided who they want, there is the draft to navigate and Roger Goodell stands at the podium and announces who goes where. In the medical education world, there is Match Day. After all the applications and visits, the medical student sits down and lists, in order of preference, what specialty training they would like to pursue and where they would like to attend. The residency directors also make their own preference list. On Match Day, a computer figures it out and decides people’s destinies. For those medical students who don’t match, there are residency spots that didn’t fill. And since there are more residency slots than there are newly mined doctors, the unfilled spots are also prime opportunities for foreign medical graduates to advance their training.

There is plenty of pressure for college athletes to perform at the scouting combine. Only 328 are invited with the expectation that they are the best players out there. It will take a few years to see whether they rise to their potential and stardom. The same time frame will determine if the medical student draft was able to produce capable, caring doctors that will serve patients well. The only difference is that the NFL makes headlines while medical training continues in relative obscurity.

aching backs

nospam@example.com (Dr. Ben Wedro) — Mon, 13 Feb 2012 09:23:35 -0700

Construction and factory works may have a special place in their heart for Derrick Rose of the Chicago Bulls. They can relate to waking up with back stiffness that makes it hard to get out of bed. They can relate to suffering through ha shift at work as their back tightens and makes it difficult to bend over. They can relate to having so much pain that it hurts too much to work. A week of low back spasms has caused Rose to miss two basketball games and he is on his way to a back specialist for further care. Regular people can’t relate.

Low back pain strikes almost everybody sometime in their life. Usually, it’s a pulled muscle from lifting a too heavy object or from spending too much time bent over or from a minor fall or accident. The structures that surround the back and protect the spinal cord usually are able to tolerate day to day stresses applied to the back but on occasion, a twist or pull or jolt tears a muscle, pulls a ligaments or stresses a disk. Pain reminds a person that they’ve done something that the body doesn’t like and it’s time to assess the situation. While elite athletes rush to a chiropractor, physical therapist or back specialist, most normal people try to treat themselves b ybeing kind to their body and taking it easy.

Going to the doctor for an acute backache can be very frustrating. There can be a disconnect between what the patient wants and what the doctor thinks they want. Patients are often concerned that something structurally wrong is happening in their back while the doctors think that the patient just wants pain relief. Pain relief is a good thing, but doctors teaching and patients understanding works better. It doesn’t help that the questions asked may seem to have no connection to the back problem itself. What does bladder and bowel function have to do with the back anyway?

When a patient presents for low back care without a major injury or fall, they can be put into two categories, impending disaster or not. The diagnosis that is a true neurosurgical emergency is cauda equine syndrome, where the nerve roots that leave the end of the spinal cord become inflamed or trapped and stop working. This can cause significant pain and numbness in the legs and back but it also causes problems with the bladder and bowel. If the patient cannot empty their bladder and goes into urinary retention or if they lose control of their bowel and become incontinent of stool, red flags go up that the spinal cord is at risk. Paraplegia is the complication of cauda equine syndrome and time is of the essence to make the diagnosis and get a neurosurgeon involved. AN MRI needs to be done yesterday.

If there aren’t any bowel or bladder issues, then there is all the time in the world to sort things out. If no there is no trauma or fall, then most times, plain x-rays of the back aren’t needed because it is unlikely that there is a broken bone in the back. Instead, a thorough exam of the back and legs to look for inflammation of the sciatic nerve is the most important test that can be done. If muscle power, sensation and reflexes are normal, then symptomatic care is an appropriate first step in helping the back get better. Most recommendations suggest that bed rest is not necessarily the best thing to do; instead, activity as tolerated gets the back moving again. Medications might help to attack the pain symptoms in different ways with anti-inflammatories, pain medications and muscle relaxants. Each doctor has their own approach depending upon the patient’s situation.

Prevention is a much better way to go and it’s a lifelong commitment. The body is a tool that needs to be well maintained just like any other machine. The spinal column is in the middle of a circle of muscles that include not only the back but also the abdominals. These core muscles need to be strong and flexible to allow the spine to do its job. AS well, excess weight puts a strain on the back, especially if there is a beer belly pulling the top of the body forward and down.

People are less than thrilled about being prescribed weight loss, pilates, yoga and stretching to prevent future back problems. This is where the doctor teaching comes in. It is too easy to write a pain prescription and shoo the patient out the door. Neither party feels particularly fulfilled about the visit. Instead, the doctor needs to take the time to explain why the back hurts, what structures are involved and what tests may or may not be helpful in sorting things out. The patient needs to understand what’s happening and ask questions if the situation seems fuzzy. Treatment options are just that … options. They may include exercise, medications, physical therapy, chiropractic manipulation or a combination of any or all. The purpose is to get the patient back to their normal functional capacity as soon as possible and to prevent future back issues.

medical mistakes

nospam@example.com (Dr. Ben Wedro) — Tue, 07 Feb 2012 07:18:13 -0700

The latest Super Bowl is now history with memorable runs, catches and tackles. It commands a huge stage and it is a reminder that most fans want to see one team perform at a high level to win the game instead of making mistakes to lose it. Tony Dungy, television commentator and former NFL coach commented that he would speak to his players and remind them that mental preparation was key to winning the big game and they did not want to be that person to make a mental error. While it was acceptable to lose the physical battle on the field, a mental lapse was inexcusable. The same philosophy rings true for many who perform including those whose stage is the patient bedside.

Medical errors will happen regardless of the caring and well-meaning of the physician and nurse. The complexity of the human body and the increasing sophistication of medical care create many opportunities where things will go wrong. From complex technology to the most simple of medications, from the initial evaluation of the patient through diagnosis and treatment, every step of medical care can be the site where an error may occur.

While it may be an individual who makes a mistake, according to the 2007 Joint Commission Annual Report on Quality and Safety, the reason for the majority of bad outcomes is poor communication, not only between doctors and nurses but between doctors, patients and families. Less experienced providers sometimes rely on technology to affirm their clinical opinions and patients take comfort when xrays, CTs and other tests are used to look for the reason for their complaints. This reliance can lose sight of the fact that most diagnoses are made by talking to the patient and listening carefully. Patients and family need to listen as well and understand what the doctor recommends and how that might impact their situation.

A couple of examples:

Pulmonary embolus or blood clot to the lung can be a life threatening condition and the patient may complain of chest pain and shortness of breath. Usually the clots arise in the veins of the leg and pelvis and travel to get lodged in the lungs to cause symptoms. Usual risk factors include long travel in a plane or car, surgeries that require the patient to be bedridden and trauma. D-dimer is a screening blood test that measures blood clot breakdown products. It can be used to exclude the diagnosis of pulmonary embolus in LOW risk patients but a negative test in a high risk patient is not helpful. As well, the test is always positive in many situations like pregnancy, cancer and trauma (the test doesn’t care where the blood clot is located. The test to confirm a pulmonary embolus is a CT scan. Reliance on the results of a d-dimer demands that the doctor know the situation, otherwise a decision error can occur and a CT that should be done isn’t or a CT that shouldn’t be ordered is.

Many people take Coumadin to thin their blood and prevent blood clots. Atrial fibrillation, an irregular heartbeat is one indication as are deep vein thrombosis and pulmonary embolus. The dosage of Coumadin needs to be individualized for each patient just like the three bears, not too much, not to little but just right. When antibiotics are prescribed, the metabolism of Coumadin can be affected and the dosage adjusted. The doctor needs to remember to do this but the patient and family also need ot be aware that drug interactions may occur and question that potential. Too much anticoagulation can cause life threatening bleeding.

When a patient presents with abdominal pain, one worry is appendicitis. The classic symptoms of pain in the right lower quadrant pain, fever, vomiting and loss of appetite help make the clinical diagnosis. Some patients, though, don’t read the textbook and if the physical examination isn’t compelling, a CT may be ordered to look inside the bely without necessarily cutting into it. Unfortunately, it may take 12 hours for a CT to show inflammation surrounding the appendix and if the test is done too early, a false sense of security may develop and the diagnosis is missed. When the diagnosis is uncertain and the patient is stable, watchful waiting may be the best test to do. Talking to the patient combined with a repeat exam may help sort things out. However, both patients and doctors sometimes lack the patience for this approach. It takes communication and trust.

Some bad outcomes cannot be prevented. Some patients with diabetes or peripheral vascular disease are at increased risk of infection and poor healing. Some patients who need to be on blood thinners like Coumadin or Plavix will bleed even if their medications are appropriately adjusted. Some patients will be too ill or injured to survive an injury. Like on the football field, games can be lost if the other team plays better and infections, diseases and trauma are formidable opponents. For that reason, Hippocrates’ writing in Epidemics becomes a mandate for those practice medicine: Primum non nocere, first do no harm. Though the phrase is not found in his oath, its words bind those who care for patients.

Winning is the only thing that counts in medicine but complications and bad outcomes do occur. The goal is not to be the person who makes the mental error that loses the game.