Victoria Wood - University Interview

"A nervous schoolgirl is interviewed as a potential student at a medical school. One of the funniest sketches ever. Sadly, she'd probably be good enough to get in now."

I'm glad that we don't have anyone like this in My Medical School. Psychologists are trained to "mirror" responses when talking with patients so their own beliefs and biases will not discourage a patient from disclosing important information...

But this is ridiculous! And rightfully so. :)

via Clinical Cases and Images via New Media Medicine

Blogging & Clinical Cases

DB's Medical Rants had a podcast reflecting on his one millionth hit. He talked about writing -- how his blog initially started off as a way to become a better writer and express himself, but he eventually found more and more people visiting his site. He had a few tips for fledgling bloggers and I found myself thinking about my own blog and motives.

Have I been focusing too much on the audience and the reader and not enough on myself and my own thoughts? What is my purpose for writing?

I haven't been posting as much as I intended to when I first started Not My Second Opinion. There are a number of reasons for this... I initially wanted to share my philosophical musings about various ethical topics in medicine, but I've regrettably found myself with very little time and energy to post on such topics in a meaningful way. My interest in posting something drastically wanes within the first few days... sometimes I get bored with the idea or I no longer think it is postworthy. Perhaps I have high standards of what a medblog constitutes after perusing the quality of my favorite blogs. Most of all, I'm worried about being held accountable for what I say -- which I find highly ironic considering the name i had settled on for this blog.

For the new year of 2007, I am going to make a few changes to my writing tone and style to reflect more of my deeper thoughts. It will be more unvarnished and more rough around the edges, but I hope that this bluntness will encourage more discussion (and be less taxing on the small portion of my brain dedicated to being sagely and wise.)

I'm going to start a new series of entries, inspired by clinicalcases.org. Every week, I will present a case that I've seen in the hospital. It will focus mainly on the clinical aspects of differential diagnosis and reasoning through the physical exam, but I will add my own personal thoughts in at the end as an emphasis for humanism in medicine.


One of my New Year's Resolutions is to devote a few more hours a week to writing. Not necessarily here for you, but for myself as well.

Curing what was once incurable... DM1!

In the days of Hippocrates, there was very little that a doctor could do. They could recognize a few common diseases, treat the symptoms and announce its probable course.

One disease that once held a death sentence was diabetes mellitus. An old native term for it was "pissing evil," reminiscent of something diabolical... but a 2nd-century A.D. Greek physician, Aretus the Cappadocian, named it so because it was like a sweet siphon. 'Diabetes' means siphon and ‘mellitus’ means ‘honey.'

Diabetics have polyuria (excessive urine) and glucosuria (sugary urine) which attracted bees and flies. It used to be diagnosed by someone drinking a urine sample and going "Ooh, this is sweet! This means death." Unpleasant for the taster for sure... but I'm not sure how diabetics feel about finger pricks nowadays as a pleasant alternative.

Diabetes comes in two types, one in which autoantibodies attack the pancreatic cells that produce insulin (DM I)and the other in which the body starts becoming resistant to insulin (DM II.) The end result is that the body detects less insulin and cellular sugar intake drops, raising blood and urine glucose levels. This is a condition that we can only treat palliatively with medications, diet and exercise recommendations.

We do not have a magical cure for diabetes... but we have recently discovered how to cure DM I in mice!

TORONTO - Researchers at The Hospital for Sick Children (SickKids), the University of Calgary and The Jackson Laboratory, Bar Harbor, Maine have found that diabetes is controlled by abnormalities in the sensory nociceptor (pain-related) nerve endings in the pancreatic islet cells that produce insulin.
...
“We started to look at nervous system elements that seemed to play a role in Type 1 diabetes and found that specific sensory neurons are critical for islet immune attack in the pancreas,” said Dr. Hans Michael Dosch, study principal investigator, senior scientist at SickKids and professor of Paediatrics and Immunology at the University of Toronto. “These nerves secrete insufficient neuropeptides which sustain normal islet function, creating a vicious circle of progressive islet stress.”
...
Using diabetes-prone NOD mice, the gold-standard diabetes model, the research group learned how to treat the abnormality by supplying neuropeptides and even reversed established diabetes.

This is an amazing discovery that may lead to radically new treatment for this chronic disease that kills 72,815 people a year (6th leading cause of death in the U.S), not to mention that it can cause blindness, kidney disease and force people to be amputated.

Who knows. Someday, people may look back at our "dark ages," wondering why we didn't surgically remove sensory neurons expressing the receptor TRPV1 and supplementally treat with injections of substance P.

Democrat Majority Threatened?!?

There was a lot of speculation in Washington when Democrat senator Tim Johnson went to the hospital that a Democrat majority would be threatened if he lost his seat in congress. He underwent brain surgery and there was a lot of concern about his future... and of the U.S. The Democrats have only a very tenuous grasp on the senate with a 51:49 majority and in case of a tie, Vice President Dick Cheney would step in with a tie breaker.

It was announced in the news today that Senator Johnson did not have a stroke. He had a congenital cerebral arteriovenous malformation (AVM.)

What's that?

MedPage today:

"AVMs are often silent, asymptomatic, and therefore undiagnosed until a hemorrhage occurs, or some other symptom occurs that results in the person getting a CT or MRI scan of the brain that reveals the lesion."
Arteriovenous malformations are congenital vascular abnormalities, and are so called because they consistent of tangles of abnormally connected vessels, with fistulas rather than capillaries forming arterial-to-venous connections, resulting in overly rapid blood flow that does not allow for proper oxygenation of tissues.
The abnormal vessels are also subject to leakage and rupture, and can lead to intracranial bleeding that can vary in severity according to where the defect occurs.

Here's a few other links to information on AVMs.

Radiology Picture of the Day: Cerebral Arteriovenous Malformation

Discover Magazine's Vital Signs: What's That Noise In Her?
A diagnostician facing his own medical troubles tracks down a killer defect.

• I really like this one because it addresses the problems that a doctor has in his diagnosis (which I already gave away the punchline for) so the main point deals with how he goes about dealing with the strange noise he hears and his own insecurities.

Fraud Alert

I got an email from UCLA today.

UCLA computer administrators have discovered that a restricted campus database containing certain personal information has been illegally accessed by a sophisticated computer hacker. This database contains certain personal information about UCLA’s current and some former students, faculty and staff, some student applicants and some parents of students or applicants who applied for financial aid. The database also includes current and some former faculty and staff at the University of California, Merced, and current and some former employees of the University of California Office of the President, for which UCLA does administrative processing.

I regret having to inform you that your name is in the database. While we are uncertain whether your personal information was actually obtained, we know that the hacker sought and retrieved some Social Security numbers. Therefore, I want to bring this situation to your attention and urge you to take actions to minimize your potential risk of identity theft. I emphasize that we have no evidence that personal information has been misused.

At first I was skeptical that this email actually came from UCLA. I'm not a student there... why would they have my information? I looked at the linked addresses and they were all legitimate. UCLA has a link on their website regarding this incident and their response.

gorram.

I didn't think that applying for medical school would put me at risk for identity theft!

Anytime you give someone your SSN and DOB, it is reasonable to assume that you might become a victim. I have no idea why they were still holding onto my information, but I'm glad that they had the courtesy (and legal responsibility) to inform me that I might be a victim.

I put a fraud alert on my file to prevent anyone from opening up new credit cards in my name. I requested my credit report online too... and whew! No suspicious activity noted.

Here's the crux of this entry: according to the Fair Credit Reporting Act, everyone is eligible to a free copy of their credit report every year. The problem is finding out how to do that online without coming across all of those websites that want you to order extra stuff.

Type into google: "site:.gov Free credit report" and the first link is the FTC's Website on Credit. I like using the "site:" feature on google... you can use it to scan for legit resources online with "site:.edu" and stuff like that.

Anyway. I just wanted to give you all a heads up on protecting your credit. How mature of me, eh?

The fraud alert and credit reports are free. Here is the contact information for the fraud divisions of the national credit bureaus:

• Equifax: (888) 766-0008 (http://www.equifax.com)
• Experian: (888) 397-3742 (http://www.experian.com/fraud
• TransUnion: (800) 680-7289 (http://www.tuc.com

A very long post on: Vaccination

Please read this, I think it is very important... and if you lack the time, just skip to the bottom for key points.

I started reading Flea's blog just a few days ago. He wrote an entry entitled "Killed by Vaccines?" A very dramatic title, I thought. Indeed, the content was quite shocking, involving the death of a young child allegedly by the administration of the common vaccine DTP. Seizures followed for months afterwards, coming and going and Marissa passed away at the age of 8 1/2.

What does DTP prevent? I know this! The first bacteria, Corynebacterium diptheriae, can cause a severe throat infection with a thick pseudomembrane that can cause breathing problems, heart arrhythmias, coma and even death. The second bacteria Clostridium tetani has a toxoid that causes such strong spasms it can lift a person off their hospital bed, not to mention respiratory failure and again, death. The third bacteria Bordetella pertussis causes a respiratory infection characterized by a whooping cough and vomiting. It can lead to complications like pneumonia, seizures and encephalopathy.

Flea ends with this:

What makes the story even sadder for Flea is that mom believes with perfect faith that vaccines killed her daughter. She refers to the child she lost as "Marissa (victim of childhood vaccines)". It's bad enough to lose a child. It's worse to remember her with a parenthetical moniker like this one.

For readers of this sad tale, it doesn't help that this mother describes herself as a "lay-homeopath" who practices cranial sacral therapy, and "unschools" her surviving children (whatever that means). Oddest of all, Lavender Essence provides a link in her side bar to this web site that includes an article entitled "Orgasmic Childbirth".Let's be clear about one thing. There is no credible evidence that vaccines cause any negative neurodevelopmental outcome whatsoever. I'm afraid that no amount of evidence, no matter how credible, is going to change Lavender Essence's mind. Period. End of sentence. End of paragraph. Shut up now and hit "Publish Post".

Hm. The internet is a great place to bring out extremes from all sides and there was an uproar from his commenters. I read a few of his links to get more of the story. Lavender Essence's story can be read here, at mothering.com.

I did some research and I found a few facts to support her case, even if they weren't accepted by the medical community as a whole. I'm not sure if Marissa received the DTP or the newer DTaP vaccine. The "a" refers to acellular pertussis, a multivalent antigen mix that provokes the same immunogenic response with less side effects. SOME OF THE RARE SIDE EFFECTS mentioned by NIH's Medline for DTP are:

collapse; confusion; convulsions (seizures); crying for three or more hours; fever of 40.5 °C (105 °F) or more ; headache (severe or continuing); irritability (unusual and continuing); periods of unconsciousness or lack of awareness; sleepiness (unusual and continuing); vomiting (severe or continuing)

oh my. The internet is a great place to find these sorts of rare occurences and amplify their responses. I think that it is important to recognize that these are rare side effects and should not be a reason to refrain from giving your children the DTaP vaccine. Perhaps if Flea had emphasized this more than the mother's "altie" beliefs, he would not have provoked such anger.

Here is my long post to the mother, which elucidates my own position:

Barefoot mama,

I too found your link through Flea's blog. I am a first year medical student and I wanted to thank you for sharing your experiences with the world. It is a brave thing to do and it sounds like you don't deserve the criticism and mockery you're receiving from so-called "rational people." It doesn't lessen your pain to have your views ridiculed and I am sorry that you have suffered even more in the sharing of your story.

You've lost a love of your life after so many months of hardship and suffering. Your daughter died from something that the medical profession struggled to understand, but failed. To make matters worse, many of them were dismissive and unsympathetic to your concerns. That is regrettable and I will strive to use this as a reminder to myself to be different when I have patients and need patience. :)
Believe it or not, but the majority of a good diagnosis comes straight from patient history, not the blood sticks, labs and scans that are done at fancy hospitals. A good diagnostician recognizes the trends and notes when something is up. It sounds to me like you were in the position to recognize a suspicious trend in Marissa, linking vaccines with the crippling seizures that she experienced. Your doctors were dismissive of them at first, because it is a rare occurrence to get such a violent reaction.

I typed in "vaccine side effect seizure" into PubMed just now, the repository of scientific journals, and I came up with one link on "immunization with DPT vaccine activated thiosemicarbazide-induced convulsive syndrome in mice." This shows a causal link in mice between DPT and seizures... which I found curious, even through my puzzlement of the Russian to English translated article.link:(Kovals'kaia, 1980.)

I do not post this to provide you with more evidence that your daughter suffered as a result of shots. I do this to let you know that I take your views seriously.

When I type in "vaccine seizure" into PubMed, the first link that comes up is this: [edited for length and grammar] "The boy started having attacks and jerks after the first injection of DTP. The EEG confirmed the typical features of hypsarrhythmia. Intramuscular ACTH was commenced for 2 weeks. No problem was reported until the age of 9 years when he started having attacks of jerking. He was treated with sodium valproate. Another 11 year old boy, his second cousin, had momentary black outs. The EEG showed findings of idiopathic epilepsy. Treatment with sodium valproate was commenced. The children of both cases belong to a family in which there is a tendency to seizures. It seems unlikely the triple vaccine produced the infantile spasms in case 1." (emphasis mine)(Lapatsanis, 2006.)

It is a dangerous thing to be misled by false information, be it "vaccinations can cause serious seizure disorders that would otherwise be preventable" or "vaccinations are dangerous to your health." Understand that Flea speaks bluntly not out of disrespect to you and your beliefs, but in the full understanding of the SEVERE consequences that would take place otherwise. He knows what diphtheria, tetanus and pertussis could do to a child. If you did not vaccinate and Marissa contracted one of these diseases, she would have suffered. Less than a handful of people contract tetanus each year, not because of any decrease in the prevalence of Clostridium tetani bacteria in rusty nails and dirt. Tetanus is not seen in hospitals precisely because of the aggressive public measures that have been going on in the past 100 years. Many doctors nowadays would consider themselves "lucky" (in purely academic sense) if they get to see a case of tetanus in their lifetime. Still they, know that a patient starts having a difficult time speaking (aka lockjaw) which progresses into muscle spasms that cause the entire body to arch back painfully, lifting the patient off the bed. When their diaphragm is involved, breathing is impaired and the only thing you can do at that point is put them on a respirator, pump them with meds and pray.

Imagine if instead of seizures, Marissa had tetanus and you had to live with the regret of knowing that you could have saved her life with a simple vaccine. This is basis for the “righteous fury” borne of medical professionals who see something they could prevent with simple public health measures, but parents refuse treatment. Flea is scared that you’re spreading false information and scaring people into refusing a vaccine. In fact, you might be spreading true information and there is something that doctors CAN do to intervene if a reaction to DTP is noted earlier. You might be speaking in the full understanding of the SEVERE side effects of a vaccine. Wikipediasuggests that you’re not alone. The thing is, this is not backed up by current literature and Flea’s position is. Additionally, the newer DTaP vaccine has a significantly reduced number of side effects. Why is DTP still used? A non-profit org called the "National Vaccine Information Center" claims that the profit margins for pharm companies are cushier with the more dangerous vaccine. *tilts head* That’s certainly something to get angry about, IMO.

Understand that everyone had their own experiences and emotions to color their comments. Flea’s are colored with his interactions with wary and resistant parents. Yours are colored with negative experiences with doctors. There are all sorts of parents and all sorts of doctors and it is unfair to stereotype either category as ignorant, stubborn and deaf to everything that does not fit their beliefs.
At the very least, consider yourself blessed that you found a good doctor. If any of your other children begin to manifest seizures of a familial type around 10 years of age, as the second article I cite suggests, you know who you can trust and who you can go to for advice on how to proceed.

Thank you for educating me. I will share my information with my fellow medical students and perhaps future tragedies can be averted and bonds of trust between patient and doctor will not be broken.

Kind wishes to you and yours,
Not My Second Opinion

I wrote this before I looked at a few more links about the old DTP vaccine, so I wasn't aware of all the goings on. Medicine tries to protect medicine and sometimes, it fails for a few people. Is it a deliberate cover-up? Are pharmaceutical companies or the government being negligent? Do we need to be so strict with vaccine administration?

It is sad that people suffer from disease. It is regrettable that we have a cure for some of these diseases -- a cure that comes before we get sick, but a cure nonetheless -- and some people refuse the cure. It is even worse when the cure makes someone sick, but their suffering is dismissed or attributed to something else by the people who are trying to make them better. Am I making sense? I sure hope so.

Key points:
Mom gets a DTP for her baby
Baby has fever that night and starts having seizures
At 13 months, she has a pattern of status seizures every fourth day
At 8 1/2 years old, her brain stem swelled up and she passed away
Is this a side effect of DTP? [edit (12/12): just to clarify, I'm only talking about seizures]
YES, but it is rare
Parents should be advised of side effects and educate their doctors if they do not know!
Docs are human too.

How To: Request Letters of Recommendation

I checked my email today and I was happy to see an email from an aspiring pre-med in My Medical School's mentorship program. He asked me the following questions about Letters of Recommendation (LORs):

1. How "early" is early enough to get LOR's? I'm planning to embark on a study abroad scholarship opportunity. [...]


2. So, I don't know if I should ask a LOR right now, or wait until January, or wait until I get back?? [...]


3. Maybe you could tell me any tips or advices on a good way to ask them for a LOR, & what they expect from you in order for them to write a good one for me.

I thought that these were excellent questions, certainly ones I wished I knew the answers to when I first started applying for medical school. I mentally wince when I review all the things that I could've done much better in "round 1" that still could have used a little polish in "round 2." I'm happy to share my wisdom to spare others the same agony, not because I'm a know-it-all (though I am a wanna-know-a-lot!)

Here's what I said in response: (scroll to the bottom for key points.)

• I think that it would be a great time to ask your professors for a LOR. It gives them some time to think about it and compose it while your experiences with them are still fresh in your mind.
  (Look into whether or not your institution has a Credential filing service that can take care of your LORs for you. Your LOR writers can submit their LORs to the service and they will send the letters for you, to the organizations you request in a confidential manner. It will save on all the envelopes you have to give to your professors, not to mention the worry that comes with your insecurities about the different stages of transit.)


• When approaching someone with an LOR request, schedule an appointment with them ahead of time and take some time to sit down and talk with them. Tell them what your intentions are and what they will be writing for, especially for your liberal arts/humanities professors. Come prepared with your curriculum vitae (CV) that they can hold onto and reference as they wish in the construction of the LOR. A lot of good things come out of this visit and I learned the hard way that it is not a good idea to ask someone via email -- it's a lot more difficult to follow up with them if you haven't established that bond before you bug them about things like that. :)


• If you're wondering how many to get and who to ask, look at the reqs for the schools you're interested in. I made an excel sheet to keep track of what I needed to do for which schools by what deadlines, because it can sneak up on you all too quickly if you're not organized. I'm not sure if this formatting will work, but here's the sample categories from mine:
  
  Medical Schools//Status//Website//LORs//2ndary due//progress//fee//interview


• It sounds like you still have a lot of time, so it's great that you're being proactive and you're thinking about these things! Scout out on the internet for a sample questionnaire. Some medical schools have a questionnaire that the recommenders fill out to address various areas. "Does this student apply critical thinking to your subject? Strongly agree<-->disagree." Then it all boils down to whether or not they would score you as a "Highly recommend," "Recommend," "recommend with reservations" and "do not recommend."
  
  The strongest LOR you can get is one that says "I would go to this person if I were sick and send my friends and family to see them too, without a doubt." I've heard of cases where faculty have actually gone out of their way to call the medical school to talk about the student, but of course, you can't ask your LOR writers to do any of these things for you. :)
  

Key Points on LOR requests:
It's always better to ask early than late.
Approach them face-to-face and chat with them about your interests.
Come organized with a CV and topics they should address in the LOR.
Use a Credentialing Service if it is offered by your institution.
Follow up with your LOR writers as the deadline approaches.

Other resources to check out:
http://www.psichi.org/pubs/articles/article_75.asp
http://www.studentdoctor.net/downloads/index.asp
http://notmysecondopinion.blogspot.com/2006/06/helpful-pre-med-links.html

Food and Drug Interactions

Last month, an antioxidant found in red wine was found to increase metabolic rates in humans and mice. Resveratrol has an implicated role in aging as it has been shown to extend the lifespan of rats (scroll to the very bottom), but Abel PharmBoy cautions us not to take these preliminary results too far. Wine also has tannins (procyanidins) that have a protective effect against heart attacks by suppressing the synthesis of a potent vasoconstrictor, endothelin-1.

Time to celebrate! What a great excuse for the upcoming Christmas holidays. ;)

If you're also celebrating with some red wine because of a miracle MAO inhibitor drug that has given you your life back after severe depression--
STOP!

My Pharmacology textbook by Golan told the tale of a young woman, Phyllis, who was prescribed a new drug to treat her depression. She recovered and went to a wine and cheese gala event to enjoy her favorite chianti with some fava beans. *cue disturbing Hannibal Lector slurping*

A short while later, Phyllis had a throbbing headache in the occipital region (back of her head) and recalling her doctor's instructions, she went to the ER. It was a good thing too... she had an alarmingly high blood pressure and she could have died. A new side effect profile was later proven linking tyramine-rich foods with MAO inhibitors. Tyramine resembles other neurotransmitters in her body and an excess release of these catecholamines kicked her body into high gear.

The following tyramine-rich foods are contraindicated with MAO inhibitors, according to the FDA:

Alcohol: Do not drink beer, red wine, other alcoholic beverages, non-alcoholic and reduced alcohol-beer and red-wine products.
American processed, cheddar, blue, brie, mozzarella and Parmesan cheese; yogurt, sour cream.
Beef or chicken liver; cured meats such as sausage and salami; game meat; caviar; dried fish.
Avocados, bananas, yeast extracts, raisins, sauerkraut, soy sauce, miso soup.
Broad (fava) beans, ginseng, caffeine-containing products (colas, chocolate, coffee and tea).

In a show of responsibility, holisticonline.com cites that St. John's Wort can be used for mild depression by minor MAO inhibiting action and therefore, tyramine-rich foods should be avoided.

Drug toxicity is often the cause of adverse side effects in the drug-food interaction. Other food-drug interactions are not as dramatic as the "cheese reaction." Still, there are other interactions that you should be aware of:

• Grapefruit juice has a very broad spectrum of competing drug effects. It inhibits the drug-metabolizing enzyme CYP3A4 in the intestines. Complicating matters in elderly people is the issue of "polypharmacy," taking numerous medications along with a high consumption of grapefruit juice. Calcium channel blockers, cholesterol medications, some psychiatric medications, estrogen, oral contraceptives and many allergy medications are affected by grapefruit juice.
• Alcohol can overwhelm the liver as it stops metabolizing drugs and starts converting the alcohol instead. This leads almost universally to drug toxicity and possibly even overdosage.
• Caffeine stimulates the central nervous system and certain drugs amplify its jittery, excitable effects. Bronchodilators (like theophylline and albuterol) and quinolone antibiotics (like ciprofloxacin)

It is ironic that certain things in our diet like cheese, beans, miso soup, grapefruit juice, caffeine and alcohol increase the concentration of drugs. You'd think that would be a good thing... but it is a tricky business, titrating drug concentrations to specific doses that are effective without being harmful. Leave the drug dose tampering up to the doctors and pharmacologists.

Be sure to check the instructions of any new medications you take to be sure that you're being safe! :)

The sites I checked out:
http://www.treatmentonline.com/treatments.php?id=1042
http://www.holisticonline.com/Herbal-Med/hol_herb_med_reac.htm
http://vm.cfsan.fda.gov/~lrd/fdinter.html

Back to the Suture

I'm fond of scars. They impart a sense of history with pain and suffering, then regeneration and recovery. They mark a person as different and the scar-bearer is changed forever. I've talked about a few of my scars in a previous entry. There are many more which are equally apparent and their stories are equally clumsily ridiculous. Enough about me, though...

Let's say that you get a nasty gash and you go to the ER or your neighborhood friendly family physician to get patched up. What goes into this process? What should you know? I will split this up into two parts, general instructions for patients and tips to keep in mind for doctors.

For Patients:

• You stumble into the office seeking help and you've just been told to take a number and sit down?!? Relax, you're not going to die of exsanguination. Unless you have a scalp wound. Those buggers keep on bleeding until they are stapled or sewed shut.
• It's a good thing you came in early. Even a short delay of three hours can greatly increase your risk of infection.
• You've had your tetanus shot in the past 5-10 years, right? Good. If not, expect to get a needle in your shoulder to make sure that you don't get lockjaw and die of tetani spasms as your whole body locks down and you stop breathing.
• Have you ever had an allergic reaction to iodine or iodine dye or anything like that? Then why is the doctor giving you BETADINE?!? Well... betadine doesn't cause an allergic reaction because of its chemical makeup.
• Have you ever been told that you have an allergy to lidocaine? Then why is the doctor giving you LIDOCAINE?!? Well, you're actually allergic to the preservative in the bottle and chances are high that you're getting the preservative-free version.

YEOWCH! The topical anaesthetic takes away most of the pain, but you still feel like wincing a bit from the uncomfortable feeling of someone tugging on your flesh to knit it back together. You're a brave trooper! :) What do you do now that you have spiky threads and a tender wound?

Here's what you need to know about your wound care:

• Keep it dry for ONLY 24-48 hours.
  It is okay to wash the wound carefully after that with soap or shampoo. Keep it clean.
• Daily washing can be supplemented with a little hydrogen peroxide to bubble off sticky bits of scabs (coagulum.)
• You don't need any antibacterial ointment. It's important that it is exposed to air; it helps with the healing. KEEP IT CLEAN, though.
• Go back and get your sutures removed as directed.
  Face: 3 days (cosmetic); 4-5 days (less cosmetic)
  Scalp, trunk, extremities: 7 days
  Joints: 10-14 days max
  Palm, soles: 14 days
• Steri-strips with may be placed in a "ladder" formation (rungs going across & the legs securing it on)
  
• Initially, your wound will look... okay. Nothing too bad.
• Then in about 2-3 weeks, it will get thick and red and tender and lumpy... some might even say ugly. Don't worry, this is normal.
• In 6-12 months, the scar you see is the scar you get. The affected area will never regain its original strength back, but it is important to stretch it so you don't lose its flexibility.
  

For Doctors:

1. The "Golden Period" is 6 hours. This is a period of time in which a wound can be sutured up safely with few complications like infection or scarring.The general vasculature of certain areas extends this period for some areas, 10 hours for the hand and 24 for the face; extra perfusion means better healing.
2. High Pressure Irrigation
   Use a 19 gauge needle on a 35 ml syringe to apply the needed 15 PSI of saline to reduce infection.
3. Antibiotics
   Dog/Cat/Human bite wounds require extra attention and Augmentin (875 mg BID) should be good. Most physicians feel it is necessary to prescribe a full weeks worth, but the majority of the bacteria is taken out in the first 24 hours.
4. Prep the wound with betadine solution, but keep it out of the wound itself.
5. NEVER shave eyebrows. They might not grow back. Avoid shaving hair at all, if you can. Gloss up hair with antibacterial ointment to move it out of the way for suturing scalp wounds.
6. Anaesthetics:
   NEVER use Lidocaine with Epinephrine on "fingers, nose, toes, hose and lobes" because Epi's vasoconstriction effects can cut off blood flow.
   The toxic dose of lidocaine is 50 cc of 1%.
   Bupivicaine is a great alternative to lidocaine. It has a slower onset, but the fact that it wears of slowly also has HUGE effects on patient comfort.
   Avoid injecting anaesthetic directly into the pads of the fingers; use digital blocks instead to numb up the entire finger instead. You're not using lido w/ epi on the fingers, right? Good! :)
7. Count the stitches you put in or have the patient keep track of them. Many people want to know the exact number for comparison's sake. Be prepared to give them an answer.
8. If you have nurses provide wound care instructions, make sure they don't say "keep the wound dry." This will make it very difficult to remove the stitches later on because of the extra tacky coagulum.

Source: the wonderful Dr. Waters
Thanks for a thorough and excellent suturing workshop!

your tapper is all fried

Signs of Congestive Heart Failure
TORCHED TAP

Third heart sound
Oedema
Rheumatic heart disease
Crackles in lungs
Hepatomegaly (tender; possible hepatojugular reflex)
Elevated JVP (jugular venous pressure)
Displaced PMI (point of maximal impulse)

Tachycardia
Ascites
Pulses alternans

your HEART FAILED

Causes of Heart Failure
Your HEART FAILED
Hypertension
Endocrine (hyperthyroidism, thyrotoxicosis)
Anemia
Rheumatic heart disease (RHD)
Toxins
Failure to take meds
Arrhythmia
Ischemia/Infarction/Infection
Lung (PE, pneumonia)
Electrolytes (renal failure)
Diet (beriberi, salt, fluids)