Types of Shock

People in shock need to relax with some COVe SAND.

Cardiogenic
Obstructive
Volume(hypo)
e

-Septic
-Anaphylactic
-Neurogenic
Distributive

S, A, and N are all types of Distributive shock (where volume mobilized into the interstitial fluid because of infection or acute inflammation causes hypoperfusion.)
1. Cardiogenic: pump failure
2. Obstructive: mechanical impedance of blood flow
3. Volume(hypo): ↓ intravascular V
4. Distributive: ↓SVR, widespread vasodilation/vascular permeability
• Septic: bacterial Ag-induced inflammation
• Anaphylactic: hypersensitivity reaction
• Neurogenic/vasogenic: imbalance of PSNS & SNS
Clinical definitions for the progression of septic shock
Bacteremia “blood poisoning” -> SIRS -> sepsis -> severe sepsis -> septic shock
Associated with fever, chills, fatigue & malaise

Systemic inflammatory response syndrome (SIRS): 2+ of the following:
1. T > 38°C or <>
2. HR > 90
3. RR > 20 or PaCO2 <>
4. WBC >12, <4,>10% immature (band) forms

Sepsis: 2+ of the following as a result of a documented infection:
1. Rectal T > 38°C or <>
2. HR > 90
3. RR > 20
4. >1 of the following manifestations of inadequate organ function/perfusion also must be included:
a. Alteration in mental state
b. Hypoxemia (PaO2 <72>
i. (overt pulmonary disease not the direct cause of hypoxemia)
c. Elevated plasma lactate level
d. Oliguria (UOP <30>

Severe sepsis: This is sepsis & SIRS associated w/ hypotension, hypoperfusion and altered mental status
o Hypotension: SBP <90>40 from baseline
o End-organ hypoperfusion: cool or mottled extremities, weak or absent peripheral pulses; lactic acidosis; splanchnic vasoconstriction -> oliguria, bowel ischemia and hepatic dysfunction
o Altered mental status: ↓brain perfusion -> restless, agitated, confused, lethargic or comatose

Septic shock: severe sepsis complicated by persistent hypotension after fluid therapy.

References/Resources
CMDT 2006. (Hypotension & Shock, pp 477-80.)
McCance & Huether, Pathophysiology 5th ed. 2006.
eMedicine. Septic Shock. Accessed 11/26/06.

Lost in Translation

I like to quote movies. The title of this entry popped into my head as I thought about the content of this entry and I think it is especially pertinent.

A lot of people laugh about movie quotes... for me, it is about finding someone else who can recognize what I'm saying and we identify with each other. We make a connection.

This sort of "reference recognition" is the basis for a lot of jokes, even in medical school. I've made very subtle jokes about people being uptight by talking about their colonic tone... a classier version of Wayne's World's "Sphincter says what?" sort of a thing. My classmates get it right away and they thought it was hilarious.

Unfortunately, this sort of joke is hinges on its exclusivity. Only people who understand the reference get the joke. People who need the joke explained to them rarely laugh about it because in the process of explanation, the humor is lost. :) Inside jokes are brutal this way. :-\

Yesterday, my Anatomy professor was talking about raising our hands. She said "From now on, you guys will be thinking in your heads 'Infraspinatus (first 15 degrees), Deltoids!'" The class laughed. I didn't really, because I realized that this was a broader joke than I first realized. Last week, my friends made the exact same joke in reference to suprascapular nerve damage!

"How would you lift your arm if you couldn't move your infraspinatus?!?"

They took turns inventing various methods (all of which looked retarded.) Batting up the arm with a flick of the hip up into the air won first prize. I said 'man, I hope you guys don't crack up when you meet a patient who does the exact same thing!' I meant it in a nice way. Sort of.


The purpose of this joke, of course, was for reference. Now that we laughed about it, we would never forget which muscles ABduct the arm and when they worked.

However... these jokes don't work on the laypeople! A lot of things I find completely hilarious right now wouldn't make any bit of sense to non-medical types.


Even worse, I'm afraid that I'll forget this more and more as I become a doctor. Sarah talked about this earlier today, mentioning how third-years at the homeless clinic were asking their patients if they had "hematochezia," which is basically blood in their stool. "Stool?!?" she added... "they don't even know what stool is!!! Say poop."

A lot of things get lost in translation. For the sake of my future patients though... I'll have to remind myself to become well-versed in cute and poetic analogies to explain things. I've got a few already that I'm awful fond of and I know that they will be more valuable than most of my medical knowledge when I communicate with patients.

It isn't about dumbing down the vocabulary. It isn't about talking down to the patient. It is about effectively communicating with them so everyone is on the same page! They won't tune out the big intimidating words. I'll work hard on giving them just one a session and try to include one analogy or story. I think that this will take me far in translating medicalese into something that is actually INFORMATIONAL.

How cute. I think I started already with this entry. :)

Apple/day

I was in a study group session this past weekend and we were discussing a farmer w/ pneumonia who didn't go in to see the doctor until it got really bad.

The question came up: "why do some people refuse to see doctors?" I was responsible for writing that part of our study guide up and I just wrote a few notations about the topic.

Be 2) Why do some patients avoid going to the doctor?
· Support (from partner, low finances, etc.)
· Not help-seeking
· Afraid of diagnosis – “not sick until the doctor tells them that they are”
· No time, lot of work = stress + better things to do
· No trust in physicians

I wanted to talk a bit about #3 here. "Afraid of diagnosis."

People have ths idea that we are born perfect and healthy into this world, but unfortunately, that is not true. It has been said that we start dying the minute we are born. Technically, we start dying even before that while we are still in the womb.

We fight a constant battle to acheive tenuous homeostasis.
We have to work to stay healthy.

I think a big reason why people with high blood pressure, high cholesterol and high glucose don't want to see the doctor is because they feel healthy. They don't want to hear how their sodium, fat and sugar might be affecting them. They don't want to hear how eating right and exercising might save their life and positively affect their quality of life.

They don't want to be sick.

Are they sick? Diagnosing someone with "Hypertension", "Coronary Artery Disease" or "Diabetes Mellitus" doesn't change who they are. It doesn't necessarily change how they feel either, though the hope is that their feelings will change their behavior.

The approach I think that should be used is to tell them that if they don't feel sick, then they aren't sick. However, they do have a problem that could be fixed with some lifestyle modification. Too much influence from environmental or genetic factors might require pharmacologic intervention. On this, I'd say the following:

"Just because you're taking medication it doesn't mean that you've got a disease or an illness. You're taking these pills to prevent you from getting sick. "

This apple a day will keep the doctor away... the single ounce of prevention that'll be worth a pound of cure.

Random Statistics about "Five"

"Did you know that each cigarette you smoke robs you of 5 minutes of your life?"

This is a statistic that I should have mentioned this past weekend when a friend of mine was chastising someone at a party for smoking. I didn't want to get too involved because I knew that it was a "downer" type of talk to be having at a fun birthday party... but it is important to realize how bad smoking can be, if not for yourself, but for those around you as well. It has been proven to exacerbate asthma. It can lead to lung cancer and emphysema or chronic bronchitis, two examples of COPD (chronic obstructive pulmonary disease.)



Five is bouncing around in my head today.
Tuberculosis (TB) is an infectious lung disease that has a chance of being "reactivated" after the initial infection.
So you have a 5% chance of getting reactivated TB in the first 2 years.
Then there is an additional 5% lifelong chance of reactivation
And for people infected with HIV, a "high-five" or 5+5% chance of being infected EACH YEAR!

That's all I got, folks. Hopefully I can spare some time to organize my thoughts better and write something out.

One less reason...

Photo credit: superfantastic on Flickr

I'm trying to hit the 5 R's of smoking cessation . There might be a number of roadblocks for smokers towards a successful quit date.

"Oh, I tried, but I had a hard time."
"I didn't know how to start."
"It's hard because I don't have any support."

If any of these reasons sound familiar, then you now have one less reason to continue smoking!

Here are some resources I found online that might help you, + 1 for doctors.

CME webcast for doctors

Office resources and patient education materials

Smoking: Steps to Help You Break the Habit
A good website from Familydoctor.org about smoking addiction and how to quit

National Network of Tobacco Cessation Quitlines
DDHS has a national quitline number, 1-800-QUIT-NOW
The toll-free number (1-800-784-8669) is a link to the national network of tobacco cessation quitlines

Nifty interactive Quitline map, showing local websites, phone numbers and services
http://www.naquitline.org/index.asp?dbsection=map&dbid=1

More than a number

What exactly does 200 Calories mean?

One calorie is a measurement of heat that it takes to raise 1 gram of water 1 degree Celcius at 1 atmospheric pressure. A "Calorie" with a capital "C" is a kilocalorie... and the unit that we usually refer to in our diets. So, 200 Calories raise 200 kg of water 1 degree celcius.

That's a fun fact for trivia geeks, but nearly meaningless to people who are trying to diet.

Here's a website that shows you what exactly 200 Calories look like.

iVillage has a few tasty 200 Cal snack options and the Cleveland Clinic has a few other 200 Cal recommendations.

Alternative source of stem cells

My favorite thing about science is that discoveries are borne out of necessity. Progress is rarely hindered by obstacles and restrictions; they are simply hurdles to be overcome. Rising gas prices, global warming and consumer dissatisfaction will drive us to seek alternative fuels.

Similarly, the moratorium on embryonic stem cell research has forced researchers to consider alternative sources for stem cell research. Amniocentesis is a procedure performed during pregnancy to diagnose a number of genetic and chromosomal abnormalities. Down Syndrome, spina bifida (or other neural tube defects like anencephaly), Rh factor incompatibility and lung maturity can all be detected.

Recently, researchers at Wake Forest University School of Medicine have found that left over amniotic fluid has stem cells in an intermediate stage between embryonic stem cells and adult stem cells. Leftover amniotic fluid can stored in a bank and with a storage of just 100,000 specimens, a perfect genetic match can be made for 99% of the U.S. population, potentially revolutionizing transplantation.

If these preliminary results withstand political and scientific scrutiny, we may be on the brink of a whole new line of research with direct medical benefits.

http://www1.wfubmc.edu/news/NewsArticle.htm?Articleid=2020
http://www.biotech-weblog.com/50226711/stem_cells_derived_from_the_amniotic_fluid.php

5 Rs for Encouraging Behavior Change

We were taught this in the context of smoking cessation, but as the teacher pointed out, it can be used for much more than that.

• Relevance:
  Tailor advice and discussion to each patient
• Risks:
  Outline the risks of continued smoking
• Rewards:
  Outline the benefits of quitting
• Roadblocks:
  Identify barriers to quitting
• Repetition:
  Repeat the message at each visit

Eschara

Got a scar story?

I told one about my most memorable Halloween, when I took a spill on a bike and had the most grotesque face for months afterwards. Little bits of spidery black stitches, hot red slashes across my cheek and jaw... yuck.

Anyway, an annotated version of it is on Eschara. I think that this has the same appeal as Post Secret does, in revealing an intensely personal story to the world but at the same time shielded by anonymity.

I really like this idea, so if you have a digital photo and some time, feel free to submit a tale of your own accidental tattoo. :)