Jan 30 - Lessons with Dr. J

Hyperventilation and Emesis (Vomiting):



"Remember the case this Monday?", says Dr.J
"yes" I squeaked.


Last Monday, I appeared to be apprehensive in Dr. J's eyes, when I expressed my worries that patient had told me that she had a extreme case of a needle phobia.

ap·pre·hen·sive  

/ˌapriˈhensiv/

Adjective Anxious or fearful that something bad or unpleasant will happen. Of or relating to perception or understanding.

Synonyms anxious - fearful - afraid

so back to today.

We had an unusually long surgery in one case... because of the 'red stuff'.

Later when I failed to have the patient follow my breathing instruction, Dr. J told me, "you have to coach" I observed as the Nurse waited for her to take her instruction.

"Remember we are professionals, so we have to take 'control' of the situation and lead the patient - do you know any parents controlled by their children? -  it's a disaster. - we have to be the one reassuring patients."

said Dr.Johnson - as T came over and calmed the patient down and she went back to normal breathing --> less bleeding --> quicker surgery.

As patient was hyperventilating, he asked me a question. 

"What happens when patient hyperventilate?".

And as always I fumbled... 

[just like I did when we discussed the reason why Dr. J put pilocarpine in one eye that he was operating on: 

"I couldn't find any reason based on her chart....aniscoriasis?". 

"...you mean aniscoria?" -

Reason: Asian & hyperopia (aka farsightedness) - concluded from + A/R reading ("that's why A/R reading is important!) --> conclusion: smaller eye (shallow anterior chamber and narrow angle)--> leading to higher risk for Angle closure (Closed angle) glaucoma because a) smaller eye ...

"and bright light? so dilation...?" 

"that causes constriction!" 

"Right, SNS!!!" 

"think local!" 

"um (thinking alcane)...does it have Ach?" looks up at me 

"no..." 

"right! Epi!!"  b) Epi in local anesthetic which will activate SNS and dilate pupils in addition to activation in a stressful situation --> Big pupils pushes down which means even more narrow angle - thus drop of pilo for prevention.]

"metabolic... no reproductive..not respiratory acidosis?"

"you have CO2 out, so that's alkalosis" 

"I remember it being counter intuitive because of the bicarbonate (HCO3).... " 

So moving on to next surgery, I couldn't let go and said, 

"CO2 is going down so H2CO3 is converted to HCO3 + H+ so acidity goes up?"

and now I see that I was completely wrong!!!! how embarrassing!!!

Hyperventilation --> CO2 level decrease in blood (hypocapnia) - CO2 is carried as bicarbonate (CO2 = HCO3) (!!!!!!!) in the blood, so the loss of CO2 drives HCO3 + H+ --> Carbonic acid (H2CO3) --> H20 + CO2!! resulting loss of H+ makes blood alkaline and thus causes Metabolic Alkalosis

CO2 (g) + H20 (l) <=> H2CO3 (aq) <=> H+ (aq) + HCO3- (aq)

CO2 goes down, H+ goes down fyi: it's moving <--

in other words... 

it means: 

fyi:

Respiratory acidosis is a condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces. This causes body fluids, especially the blood, to become too acidic.

Metabolic acidosis is a condition in which there is too much acid in the body fluids.

• Diabetic acidosis (also called diabetic ketoacidosis and DKA) develops when substances known as ketone bodies, which are acidic, build up during uncontrolled type 1 diabetes
• Hyperchloremic acidosis results from excessive loss of sodium bicarbonate from the body, as can happen with severe diarrhea
• Lactic acidosis is a buildup of lactic acid. It can be caused by:
  • Alcohol
  • Cancer
  • Exercising for a very long time
  • Liver failure
  • Low blood sugar (hypoglycemia)
  • Medications such as salicylates
  • Prolonged lack of oxygen from shock, heart failure, or severe anemia
  • Seizures

Other causes of metabolic acidosis include:

• Kidney disease (distal tubular acidosis and proximal renal tubular acidosis)
• Poisoning by aspirin, ethylene glycol (found in antifreeze), or methanol
• Severe dehydration

Clinical implication of hyperventilation:

- lowers Intra Cranial Pressure

- Hyperventilation --> CO2 decreases --> Alkalosis --> Normally, alkalosis lowers neuronal excitability (pH: 7.4 → 7.8). Alkalosis causes H⁺ to move out from the cells and K⁺ to move in to the cell, leading to hypokalemia. This leads to a higher concentration gradient between intracellular and extracellular K⁺ leading to more K⁺ exiting the cell through leakage channels leading to hyperpolarization of the cell. This means that a greater than normal stimulus is required to reach the threshold and thus elicit a subsequent action potential.

- A major effect of alkalosis is hyperexcitability of the nervous system. Peripheral nerves are affected first, resulting in spontaneous nervous stimulation of muscles. Spasms and tetanic contractions and possibly extreme nervousness or convulsions result. Severe alkalosis can cause death as a result of tetany of the respiratory muscles

- Muscle contraction: hypocapnia causes muscular tension, poor posture, aggression and violence.

synthesis of glutamine: 

“Studies designed to determine the effects produced by hyperventilation on nerve and muscle have been consistent in their finding on increased irritability” (Brown, 1953). Muscles and nerve cells become abnormally sensitive or irritated.

"Cortical CO2 tension and neuronal excitability". It was shown that CO2 has a strong calming effect on excessive excitability of brain areas responsible for thinking (Krnjevic et al, 1965). 

hyperventilation "leads to spontaneous and asynchronous firing of cortical neurons"(Huttunen et. al, 1999).

= pain and bleeding?????

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In other cases, there was emesis during surgery involving thyroid patient. (See Thyroid here!)

How can mere eye surgery cause emesis? Vagus nerve activation. 

Color of vomit

• Bright red in the vomit suggests bleeding from the esophagus
• Dark red vomit with liver-like clots suggests profuse bleeding in the stomach, such as from a perforated ulcer
• Coffee ground-like vomit suggests less severe bleeding in the stomach, because the gastric acid has had time to change the composition of the blood
• Yellow vomit suggests bile. This indicates that the pyloric valve is open and bile is flowing into the stomach from the duodenum. (This is more common in older people.)

Pressing upon certain places on the throat, sinuses, and eyes (also known as vagal reflex stimulation when performed clinically)

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And I just remembered something about CABG (coronary artery bypass graft)...

heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atheroscleroticnarrowings and improve the bloodsupply to the coronary circulationsupplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage ofcardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery.

The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words, a double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery andright coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five. Bypass of more than four coronary arteries is uncommon.

A greater number of bypasses does not imply a person is "more sick", nor does a lesser number imply a person is "healthier."^[17] A person with a large amount of coronary artery disease (CAD) may receive fewer bypass grafts owing to the lack of suitable "target" vessels.

Jan 21 Lessons with Dr. J and Lumps and Bumps!

This morning, as any Monday morning, I proceeded with getting the patient in, taking pictures, giving brief instruction and la~la~

Let's talk about bumps and lumps. I've been meaning to cover this base for a long, long time!

1. Chalazion - Caused by blockage of a duct that drains meibomean gland -- NON-INFECTIOUS
Treatment: apply warm compresses for 10-15 minutes qid --> soften the hardened oils blocking the duct and promote drainage and healing
Prognosis: disappear without a treatment in a month or so; if it continues to get bigger - surgically remove oil gunk - another effect: big chalazion put pressures on cornea causing astigmatism

2. If infected --> Hordeolum or Stye (external hordeola). (THINK PIMPLE! PAINFUL!)
Meibomian gland/glad of Zeis or Moll + usually bacterial (staphylococcal) infection

3. Nevus ("birthmark" L - brown, freckle like spot): sharply circumscribed and chronic lesion of the skin. This flat, benign and pigmented area may appear inside the eye or on its surface. Commonly appear on the choroid (the layer behind retina, the iris, and the conjunctiva)

4. Conjunctival Papilloma: categorized into infectious (viral), squamous cell, limbal and inverted based on appearance, location, patient's age, propensity to recur after excision, and histopathology. They are also classified based on gross clinical appearance: pedunculated (infectious conjunctival papilloma and squamous cell papilloma) or sessile. 

(Sonorandeserteye)

5. AHC (Apocrine hidrocystoma) - also cystadenoma, moll's gland cyst, sudoriferous cyst:
Hidrocystoma is cysts of the sweat glands usually on the eye lids. It is NOT tumour (hidroadenoma is)
"Whether these represent retention of cysts or benign neoplasm is controversial. When these lesions become more complex with papillary structures and increased cellularity --> cystadenoma" (DermAtlas)

Shiny skin coloured compressible cyst (DermAtlas)

6. Syringoma: harmless sweat duct tumours clustered on eyelids (also found in armpits, ubmilicus, or vulva). They are skin-coloured or yellowish firm rounded bumps.

Syryngioma (eccrine)

Gallery a la Mari 1

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Jan : Informed consent - Lesson with Dr. J

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"Ok, here's one"
As he sutures patient's entropion left lower eye lid, Dr.J asks me a question what the informed consent is.

My mind boggles down to typical pre-med answers.
Informed consent to be given to patients who are mentally capable to understand the kind of procedure they are agreeing to, if not decision makers, who, looking after the patients best interest, makes a decision for the patient.

He paused for a moment and says, "informed consent is letting patients know about "risks" and "benefits" about the "intervention" vs. "non-intervention" where the communication is an absolute key. As you can't explain risks and benefits in Latin to English-only speaking patients - communication between patients and health-care providers is most important.


Informed consent from Wikipedia:
Informed consent is a phrase often used in LAW to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant.

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Relating to informed consent.

"Patient-Centered-Care". 

"Patient-focused-care, there shouldn't even be a word, for it. It sounds like Doctors are ignorant of patients if such things are to be taught." 

"It's just like a chicken nugget advertising ' now with 100% chicken!' you wonder what was in it before."

What I realized from this paradigm shift was a sad, sad truth... that such concept had to be coined, made and taught -when it is an obvious common sense. Dr. J who thinks ethics taught in medical school is an absolute bogus sometimes expresses too strong of an opinion for me, who is a complete outsider (at least it is hard to identify with his perception at this point in my life). But given that, "policy are often made as are with campaign, by people "not in the trenches", it's rather hard to see the rational behind some of the stuff." So things are kind of out of touch with reality in a sense.

Let's think back what I remember from patient-centered-care.

That everyone is a part of a team, every professional should be well-respected and that they share a common goal - which is to say for patient's best interest - with patient-centered. 

But, when you meet some of the patients who demand too much of a health care that shouldn't give them too much privilege (because of their crying and nagging and threats) - ie.// medically irrelevant procedure which patient expects to be billed under the health care - you think if the policy itself may not be so perfect after all.

It sounds good, it looks good, but just not realistic "in the trenches" 

I like being a tourist.

Every little things look more vivid and precious.

You take notice of flickering light in a street and 
think how wonderful it is and take note of it.

I mean, When will you come to this place again to take note of it?

Being a tourist anywhere in this world

makes you little more brave, 

almost as if your inhibition is loosen, 

as if you are drunk, 

feeling the buzz.

You become more yourself...

not bound by who [you] are 

when [you] are living in a familiar place, 

that is... where [you] are from, 

where [you] are defined by [you]r work, 

[you]r friends and [you]r social circumstance.

You invent yourself but at the same time, 

you could be yourself completely. 

Since no body has any image of [you].

This is how I mean.

And you can very well tell that 

What I don't like are:

Image.

Prejudice.

Perhaps that is why I'm at most ease and friendliest when I don't know people.

Being a tourist allows me to do that.

Being a tourist makes me appreciate things and life in a different light.

Being a tourist also allow me to express the joys with others, 

who are also foreigners there.

Being a Tourist

I Wandered Lonely As A Cloud

I Wandered Lonely As A Cloud 

by William Wordsworth

I wandered lonely as a cloud
That floats on high o'er vales and hills,
When all at once I saw a crowd,
A host of golden daffodils;
Beside the lake, beneath the trees,
Fluttering and dancing in the breeze.

Continuous as the stars that shine
And twinkle on the milky way,
They stretched in never-ending line
Along the margin of a bay:
Ten thousand saw I at a glance,
Tossing their heads in sprightly dance.

The waves beside them danced; but they
Out-did the sparkling waves in glee:
A poet could not but be gay,
In such a jocund company:
I gazed - and gazed - but little thought
what wealth the show to me had brought:

For oft, when on my couch I lie
In vacant or in pensive mood,
They flash upon that inward eye
Which is the bliss of solitude;
And then my heart with pleasure fills,
And dances with the daffodils.

Time after work

During the last surgery,

We ended up talking about life of medical school students, its ridiculous aspect ("how unfortunately organized! when I was at medical school... ") and of being rushed with its intense curriculum ("you start electives right after second year. My daughter will start hers after her school is done in May, back here")

He said, "Now if you get into medical school this year, all you've done here will stay as a valuable experience (I think it went on like this and I agreed) enjoy the time after the work (yes, this is the only true free time that is mine and mine alone) and read all you want and spend time with friends (I feel like since I have so much time, right now is the time to make friends, make valuable memories and perhaps find a ... mate)." As you will be too busy when you get into medical school...too busy studying, since it will be overwhelming, intense and lots of information."


Friends... making wonderful memories with people that I like.
...Friends.

am I making good use of my time?

I don't think so.

I come back home...tired, eat and watch stuff until it is 8 or 9.
Wash.
Fall asleep.

I know I ought to do something more meaningful with my time.

Place to travel series 1: Bolivia - Gran Salar de Uyuni

World's largest salt flat at 10,582 square km.

Located in the Potosi and Oruro departments in South west Bolivia,

this place contains 50-70% of the world's lithium reserves, which is in the process of being extracted.

*Medical note: Li+ is used to treat bipolar disorder as it is a mood-stabilizing drug both acutely and in the long term. Lithium carbonate(Li₂CO₃), sold under several trade names, is the most commonly prescribed. However, interesting to note that  in 2009, Japanese researcher reported that low levels of naturally occurring Li+ in drinking water supplies reduces suicide rates and when you look at World Health Record, suicide is the 41st cause of death in Bolivia. Supposedly proportionally high number of people commits suicide in this country. However, the fact that Bolivia is a Latin America countries with the lowest income (GDP of $4500) and highest native presence and frequent alcohol abuse disorder should not be undermined (Arroyo, The Mental Health in Bolivia -draft: http://www.scribd.com/doc/45653836/The-Mental-Health-in-Bolivia)

One of the places I want to visit before I die.