Well my week has been exciting so far.
[8.26.18]
Starting off the semester strong with some biochemistry notes. I’ve only had one day of classes so far, and I’m already swamped with work!
Studygram: @prudent.student
Youtube: @brewingupbooks
When the unit has a bunch of crazy stuff going on and everyone is stressed
Let’s re-center and take care of these patients
Human heart in ventricular fibrillation.
Ventricular fibrillation is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly. It is the most commonly identified arrhythmia in cardiac arrest patients.
While there is some activity, the lay person is usually unable to detect it by palpating (feeling) the major pulse points of the carotid and femoral arteries. Such an arrhythmia is only confirmed by electrocardiography.
Ventricular fibrillation is a medical emergency that requires prompt Advanced Life Support interventions. If this arrhythmia continues for more than a few seconds, it will likely degenerate further into asystole (“flatline”). This condition results in cardiogenic shock and cessation of effective blood circulation. As a consequence, sudden cardiac death (SCD) will result in a matter of minutes. If the patient is not revived after a sufficient period (within roughly 5 minutes at room temperature), the patient could sustain irreversible brain damage and possibly become brain-dead, due to the effects of cerebral hypoxia. On the other hand, death often occurs if sinus rhythm is not restored within 90 seconds of the onset of VF, especially if it has degenerated further into asystole.
Causes of ventricular fibrillation are:
- Abnormal automaticity: In the healthy myocardium, the rhythm of contraction is regulated by sinoatrial node,that acts like a pacemaker and generates the normal sinus rhythm. Automaticity is a measure of the propensity of a fiber to initiate an impulse spontaneously, separated from the sinoatrial node. The product of a hypoxic myocardium can be hyperirritable myocardial cells and these may then act as pacemakers. The ventricles are then being stimulated by more than one pacemaker. Scar and dying tissue is inexcitable, but around these areas usually lies a penumbra of hypoxic tissue that is excitable. Ventricular excitability may generate re-entry ventricular arrhythmia. It is interesting to note that most cardiac myocardial cells with an associated increased propensity to arrhythmia development have an associated loss of membrane potential.
- Re-entry: The role of re-entry or circus motion was demonstrated separately by Mines and Garrey. Mines created a ring of excitable tissue by cutting the atria out of the ray fish. Garrey cut out a similar ring from the turtle ventricle. They were both able to show that, if a ring of excitable tissue was stimulated at a single point, the subsequent waves of depolarisation would pass around the ring. The waves eventually meet and cancel each other out, but, if an area of transient block occurred with a refractory period that blocked one wavefront and subsequently allowed the other to proceed retrogradely over the other path, then a self-sustaining circus movement phenomenon would result. For this to happen, however, it is necessary that there be some form of non-uniformity. In practice, this may be an area of ischaemic or infarcted myocardium, or underlying scar tissue.
Senior Shit Things I Said Today
Feral interns. That’s what I had today. Feral interns. They are on their first and second month of wards, respectively and have not had a senior in two weeks. So they don’t know how to follow orders and have been so overwhelmed that they haven’t had a chance to think about their patients.
So the fun things I had to say today:
“Why does this man not have anti-hypertensives on board? His systolics are always in the 150s.”
“Why does this infected diabetic man continue to have blood sugars in the 200s? After three days? What do you mean no one has adjusted the insulin?”
“There is no logical reason why this man should be on four antibiotics. How has this been on-going for one week?”
“Why is he still in the hospital?” Four. Times.
“Why has this man’s sodium been in the 150s for four days?”
“Why are everyone’s kidneys shot?”
“Why was the last vancomycin trough ordered three days ago?”
“Explain this cefepime. No seriously, why is this woman on cefepime?”
“Why are we scoping this woman for the second time in one week?”
“Why has this nausea been completely uncontrolled for three weeks?”
“Why has no one talked to him about his cancer diagnosis?”
“Why is the med student the only person who sees this patient every day?”
Feral. Interns. Neither of them could answer any of my questions. Nor did they want to change anything they were doing. I don’t know what the attending has been doing.
Tuesday
Doncha just love it when someone comes in to your office as a walk in actively dying from like 4 different serious conditions? Sounds like it would be some big, rare, exciting event in a rural primary care office.
I calls it Tuesday.
So there I was already 2 patients behind because I was following up with a patient who had been admitted with a septic joint and bacteremia from a bug I’ve literally never heard of (and the ID doc admitted he had only seen once before), and then this dude stumbles in to the office. And I mean stumbles. He can barely make it to the chair.
The front desk alerts my nurse that there’s a dude in the waiting room who doesn’t look like he can wait. She helps him into a room, lays him on the table, and gets his vitals. She then calmly comes and knocks on my door and gave me a stern, “I need you in 6 now please.”
I headed to 6. There I found a man with a through-the-roof blood pressure, fast-enough-to-kill-you heart rate, kussmaul breathing, teetering-on-the-edge-of-respiratory-failure O2 sat, and hey-at-least-something’s-normal temperature. Dude was gray.
From the moment I walked into the room I knew he was leaving in an ambulance. I just had to figure out why. While we waited for the ambulance I got a blood sugar (400ish, of course) and an EKG which showed some heart strain, but no active heart attack, thank goodness. I did a thorough physical exam.
I started to form a differential: A fib with RVR, SVT, sepsis from pneumonia, possible PE, diabetic ketoacidosis, stroke, hypertensive urgency/emergency, MI, intoxication, and the list went on. As I did my exam, I couldn’t really rule out anything on my list except SVT and A-fib. His vitals said sepsis. His lungs said DKA and pneumonia. His legs said CHF. His mouth said severe dehydration. His mannerisms said delirium.
The patient asked me what I thought was wrong. I answered honestly: “I think you have 3 or 4 different things going on, and any one of them is enough to cause some serious damage.” I explained my thoughts. “So you gonna start me back on my medicines?” he queried. “Nope, but the hospital will when you get there.”
“Oh really, which hospital?” he asked. “The one that has an ICU,” I fired back.
This man truly had no idea how sick he was. He had one foot in the grave and wanted to go home. Luckily some friends with him convinced him to go.
On the following tuesday we got a stack of hospital records. New diagnoses were being added every day. He had had every test the hospital could have possibly run, I thought. I called him in his ICU room and he updated me on his myriad new diagnoses and lengthy medication list. He was now almost back to normal and hoping to go home in a few days.
The next tuesday I saw him in hospital follow up. His discharge summary read like a soap opera. Pulmonary embolism. Pneumonia. Heart attack. A fib. Heart failure. Renal failure. Liver failure. DKA. Everything failure, essentially.
And yet this man sat before me looking perfectly well, no longer gray or delirious, now back from the brink of death. Just another tuesday afternoon.
The truth is we all get tired, we all get weary. In fact, if you never feel like giving up, then your dreams are too small. If you never feel like quitting, then you need to set some larger goals. When that pressure comes to get discouraged and to think about how you can’t take it anymore, that is completely normal. Every person feels that way at times.
Joel Osteen (via onlinecounsellingcollege)
disbar-deactivated20160905
Don’t think about what can happen in a month. Don’t think about what can happen in a year. Just focus on the 24 hours in front of you and do what you can to get closer to where you want to be.
Eric Thomas (via disbar)
Snapshot from Fargo 🌈 Pride last weekend! #CutestBoyEver 😁😘 👬👨❤️💋👨🌈🍭💕🎨♐️♐️🌈👬😍😛
That moment you don’t really know who you are anymore. You’re just there, floating. Hopefully you’re floating in the right direction.
I can't wait to see @oliverheldens this Friday at @skywaytheatre with @taylorbirr and @alekkringstad 😛 #DeepHouseHero
Ever wonder how they keep lil' babies still for chest X-rays? No? Well, now you know anyways.
neuromaencer
we live in eternity / but we die in time // latex background image via verluste
Source: blog.neuromaencer.com
the-med-girl
(From right to left): Scalp, Periosteum, Bone, Dura Mater Arachnoid Mater, Pia Mater, Brain.
* From right to left: skin, galea aponeurotica (connecting the two parts of Musculus occipitofrontalis, periost, bone, dura mater, arachnoid mater (collapsed), pia mater on the brain, directly connected to it (you can’t take it away).
