DIC and DOC: Is not blood the wine of life?

Being an oenophile, at one point in my life I wanted to be a sommelier, so I set myself on a path of self study of wines..

I rampaged through Rieslings
Barreled through Bordeaux,
Rootled through Riojas
And muddled through Merlot

When I first wrote that it was a sentence. But due to the scan and rhyme I decided they were lyrics.

Now that I live in Oregon, my studies continue as I partake in pilgrimages to the pastoral periphery of Portland where I pleasure my palate with a potpourri of provocative, peppery, piquant and poignant Pinots.

That sentence was brought to you by the letter P.

Previous to Portland, don’t worry those two ‘p’s were coincidental, the country whose wine’s really resonated with my palate was Italy. Perhaps because I am, ancestrally, Italian, but more than likely because they just taste so damn good. Italian wines have their quality regulated by the DOC, Denominazione di Origine Controllata.


Being an iatrophile*, at one point in my life I wanted to be a doctor, so I set myself on a path of self study of diseases.

I rampaged through Rabies
Barreled through Bronchitis,
Rootled through Rubella
And muddled through Metritis

Oops I did it again. Lyrics. Special props for connecting Barreled to Bronchitis. ‘Barrel’ works with both wine and obstructive lung diseases. I think I have a musical in the works here…

Now that  live in Oregon, my studies continue as I read, review, and reflect on the rambling range of ruthless and rampant respiratory riddles.

Note to self: Long form alliteration is much harder with ‘R’ than it is with ‘P’.

One of the rabbit holes I went down during my studies was identifying different forms of coagulopathy: Idiopathic Thromocytopenic Purpura (ITP), Thrombotic Thrombocytopenic Purpura (TTP), Hemolytic Uremic Syndrome (HUS), and notably Disseminated Intravascular Coagulopathy (DIC) which can be secondary to both liver failure and sepsis.

During my clinical rotations, while assisting a doctor putting in a central line in a patient with a multitude of comorbities including CHF, liver failure, renal failure and an acute infection that had led to sepsis, I noted purpura around the blood pressure cuff on the patient and the incision made for the line began to bleed more profusely than expected.

I exclaimed proudly, “Disseminated Intravascular Coagulopathy! DOC!”

“D *O* C”? questioned the Doc.

“Is not blood the wine of life?” I deflected pseudo-philosophically confusing everyone in the room including myself. “I’m pretty sure that’s from MacBeth” I explained.

They seemed satisfied with that justification. I’ve found you can resolve any tangent with a Shakespearean quote and people will nod like you’re smart.


*Iatrophile – A neologism I invented using Greek roots for “person who loves medicine”


 

I suggest reading this brilliant article from the NEJM by Dr. Beverly J. Hunt:

Bleeding and Coagulopathies in Critical Care

This publication is a great primer in the differentiation and management of the most common coagulopathies one might come across in the ICU.

Also I just searched MacBeth for the quote “Is not blood the wine of life?”.

Nope. I totally made it up.

 

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That’s so Hawt!

In a random medical discussion with a surgeon friend over a bottle of Oregon Pinot as we Portlandiputians are wont to do, she brought up a condition she had come across in surgery that piqued my interest.

Malignant Hyperthermia.

Despite never having heard of it (being relatively new to this field this happens a lot) it has it’s own association!

http://www.mhaus.org/ – The Malignant Hyperthermia Association of the United States.

We’ll just ignore that this is an American institution and yet the acronym they chose, “haus”, is German. I’m certain to lose sleep over that inconsistency later, but for now let’s just merrily roll along. Yesterday is done… see the pretty country side. <–You might find I quote Sondheim a lot. I encourage you to do your research in that specific field as I do mine in this one. ūüôā

So… Malignant Hyperthermia, ‘MH’ from here on in because typing,¬†is a medical crisis that is triggered by commonly used surgical anesthetics and the particular neuromuscular blocking paralytic succinylcholine. An MH crisis comes with the rapid onset of increased metabolism, muscle rigidity, tachypnea, and body temperatures that may exceed 110F.

Yes you read that right: 110F. Or 43.3C if you’re German and live in a ‘haus’. I will never let that go.

This condition is obviously, extremely deadly.

It’s also genetic and passed through a dominant gene meaning the children of an MH patient are 50% likely to also have it.

Physiologically, this gene mutation results in an abnormal protein in the muscle cells that, when exposed to certain agents, commonly anesthetics for surgery, causes a rapid deploy of calcium from the sarcoplastic reticulum, triggering hypermetabolism that depletes the muscles of their ATP leading to muscle death leading to a a potassium storm (hyperkalemia) which causes arrhythmias and on to cardiac arrest and multiorgan failure / injury.

It may be hot, but it ain’t pretty.

The drugs that trigger this are the general anesthetics in the “ane” class, Halothane, Isoflurane, Enflurane, etc. But the most serious culprit is the depolarizing muscle relaxant succinylcholine.

List of safe and unsafe drugs for MH patients can be found here. You know, just in case you were about to perform surgery and needed my guidance.

http://www.mhaus.org/healthcare-professionals/be-prepared/safe-and-unsafe-anesthetics/

MH has one antidote: Dantroline. So again, if you’re about to perform surgery ¬†you might wanna keep it handy. In fact, in most hospitals, having Dantroline at hand for surgery is… wait for it… wait for it..

Haus rules.

Because being hot is not always a good thing.

 

Always Breathe

The Hering-Breuer reflex, eponymously monikered by Viennese scientists Ewald Hering and Josef Breuer in 1868, prevents over-inflation of the lungs.

The ‘Hering-Breuer reflex’ is often confused with the ‘Herring Brewer reflex’ which causes one to throw up when eating fermented fish, a common problem with tourists visiting Iceland. I’ve been to Iceland and I can say from experience, my Herring Brewer reflex is functioning at full capacity.

Anyhoo, this reflex, the non-fish version, one would assume is simply a function of physical mechanics. The more you inhale, the less compliant the lung, the more pressure is placed on the thoracic cage, there’s pain, you stop. ¬†But no. Biology, as always, is far more complicated than that. Our lungs are colonized by mechanorecptors, biological manometers sensitive to pressure, known as pulmonary stretch receptors. These mechanoreceptors exist in many places in the body, but in the lungs they are primarily found in the pleura and the smooth muscle surrounding the bronchi and bronchioles.

Hering and Breuer also came up with name for the reflex that causes us to inhale when the lungs deflate. They named it, not surprisingly, The Hering-Breuer Deflation Reflex.

I’m not sure if back in the late 1800’s neurology had progressed to a point where we knew about mechanoreceptors and chemoreceptors. More than likely, they just stuck a flag in something they observed and called it their own. A form of physiological colonialism. “I don’t know what this is exactly but I’ll name it after me and y’all can figure out the details later…”

The respiratory centers of our brain are located in the medulla oblongata and pons sections of the brain stem. These pulmonic manometers send a signal via the vagus nerve to  the medulla. The ventral and dorsal sections of the medulla control expiratory and inspiratory movements respectively.

The pons has the apneustic and pneumotaxic respiratory centers. The apneustic sends signals to increase tidal volume, inhibited by the Hering-Breuer inflation reflex and also by the pneumotaxic respiratory center which decreases tidal volume.

The apneustic and pneumotaxic centers work in parallel to control the rate and volume of breathing. the involuntary aspects of breathing are mainly controlled by chemoreceptors that monitor the PaCO2 (partial pressure of carbon dioxide) in the blood. By managing the PaCO2 level through respiration, we control the pH level of our body.

Christopher Durang, in his play Laughing Wild, offered up this one important piece of advice that, until recently, was a mantra I lived by.

“Always Breathe”

Like I have a choice.

 

 

Post-viral cough

A friend with a lingering dry cough started asking me questions about it. I, of course, because no one ever really does, had no definitive answers. I had recently been reading a chapter in Egan’s about interstitial lung disease and on taking down his history I learned he runs his own farm. So Portlandy!

“Hypersensitivity Pneumonitis – Farmer’s Lung!”

When you’re reading about zebras, everything looks like a zebra.

Hypersensitivity Pneumonitis is a general category of ¬†parenchymal inflammation as a response to¬†inhaled organics and it can be caused by a multitude of biological compounds. There’s Coffee Worker’s Lung, Humidifier Lung, Hot tub lung, Cheese Washer’s lung, and my favorite Bird Fancier’s Lung because it’s fancy and involves birds. Each has its own pathogen at its root but the result is the same: Pneumonitis – swelling of the lung tissue. It is differentiated from pneumonia by the lack of an infectious agent.

Symptoms of pneumonitis include fever, chills. malaise. chest tightness, dyspnea, rash, headache and, of course, *drum roll* cough.

Radiographic features tend to show¬†a diffuse micronodular interstitial pattern. Which is a technical term to “giant ugly mess”.

Farmer’s lung is a form of hypersensitivity pneumonitis that is most commonly caused by moldy hay, specifically the aspergillis that thrives there.

So I see a farmer, I see him cough, I just read about zebras, I see a zebra.

However, he had had a chest x-ray. It was clear.

No stripes. No zebra.

He had however, weeks ago. recovered from a chest cold. And this lingering, nagging, dry cough just would not subside.

And here’s where I came across something I hadn’t heard of. Possibly because it is recognized as an officially recognized condition in Europe but not the USA. Those sassy Europeans. They’re always ahead of us.

Post-viral cough.

“a lingering¬†cough¬†that follows a¬†viral¬†respiratory tract infection, such as a¬†common cold¬†or¬†flu¬†and lasting up to eight weeks. ”

https://en.wikipedia.org/wiki/Post-viral_cough

There doesn’t seem to be any hard evidence as to it’s cause but there is suggestion that the infection leaves behind something that upregulates the receptors that stimulate cough. Or it’s a continued immune response upregulating the cough receptors that lingers even after the virus is defeated.

It seems American’s are hopping on board with the term “postinfectious cough” and like typical cavalier Americans willy nilly inventing words because a hyphen is really hard to find on a keyboard, they went with “postinfectious” instead of “post-infectious”. This kind of portmanteau neologism is downright Shakespearean.

You can read about it here.

http://journal.publications.chestnet.org/article.aspx?articleid=1084248

In the end, the answer, like always, is steroids. Inhaled if it’s not too bad. Oral prednisone if it’s so paroxysmal the patient can’t function.

Until I decided to go back to school for respiratory therapy, I thought love was the answer.

I was wrong. It’s steroids.

He’ll live. He’ll go back to his farm and tend to his zebras. I mean… horses.

 

 

And then you career from career to career…

After moving to Portland from New York City in 2014, after 20 years as a digital professional, I decided it was time for a career change.. I chose Respiratory Therapy because it felt like the perfect intersection of my interests in math and physics combined with desire to work in health care. All that damn empathy! Gotta put it to use somewhere.

This blog is being started a week prior to graduation from the RT program at Concorde. I should have started it sooner, so many good ideas in interesting factoids have come and gone. But alas, school, clinicals, and my alternate life as a composer/lyricist/web developer/actor/singer kept me busy enough.

This blog will serve as a place to write out ideas and experiences that led to research. I have learned that medicine is a constant¬†exercise in learning and growth. Hence the term “practice”. And¬†the act of putting things in my own words is the best possible learning comprehension process for me. And hey, you might learn something to!