septale

lillieisabllagrace  asked:

If boxers aren't in line to get evaluated, I'd like to put them there... No hurry. :)

Ah, Boxers. Clowning cancer factories. They’re such an interesting breed and frequent visitors to the vet clinic. They’re also one of the addictive breeds, meaning that despite their flaws there are a lot of people that once they own one, are never without one ever again. You might want to sit down and have a cup of tea.

Disclaimer: These posts are about the breed from a veterinary viewpoint as seen in clinical practice, i.e. the problems we are faced with. It’s not the be-all and end-all of the breed and is not to make a judgement about whether the breed is right for you. If you are asking for an opinion about these animals in a veterinary setting, that is what you will get. It’s not going to be all sunshine and cupcakes, and is not intended as a personal insult against your favorite breed. This is general advice for what is common, often with a scientific consensus but sometimes based on personal experiences, and is not a guarantee of what your dog is going to encounter in their life.

Originally posted by orbo-gifs

So, the number one thing that Boxers as a breed are known for in veterinary medicine, if there one one solitary defining feature that was the reason most veterinary professionals decide against owning a boxer, a breed they would otherwise like, then at the risk of being insensitive, (since you like sparkly gifs) its…

Boxers are prone to cancer like no other breed I know, closely followed by Golden Retrievers. They develop all sorts with great ease, at unfortunately young ages with great regularity.

Mast Cell Tumors are the bane of the boxer breed. These tumors can develop anywhere on the body, including in organs like the spleen, and in any layer of the skin. These tumors are sometimes called the Great Pretenders because they can look like lots of different things. They’re easily mistaken for benign lipomas by feel, and can be misdiagnosed if they’re growing under a lipoma by FNA as it’s easy to miss a small lump with a small needle.

While a low grade MCT has a chance to be cured with surgery of detected early, a high grade one is all kinds of trouble even with modern chemotherapy options. It’s fear of these tumors that cause many vets, including myself, to be highly suspicious of every single lump on a boxer or boxer cross.

Boxers also seem highly prone to other cancers too, lymphoma being high on the list. Individuals with a white belly also get squamous cell carcinomas and cutaneous haemangiomas.

They are one of the very few breeds known to develop malignant histiocytomas, which is especially unfortunate considering that in most dogs a histiocytoma goes away all on its own in a few months, but in Boxers it will potentially kill them.

So while any lump on any dog can be a malignant cancer, Boxer’s have the added ‘fun’ of developing lumps that probably would have been fine on an other dog and look benign but sometimes actually aren’t. Can you understand my paranoia?

Boxers are a brachycephalic breed, meaning they have shortened muzzles and flattened faces. There is significant individual variation within this breed, but more extreme individuals do suffer from Brachycephalic Airway Syndrome (BAS)

Their facial conformation leaves their eyes prone to numerous Eye Conditions, including but not limited to cherry eye, entropion, exposure keratopathy and corneal ulcers. They also get a particularly difficult to treat eye ulcer called ‘indolent ulcers’ which are sometimes just called ‘Boxer dog ulcers’. They also get progressive retinal atrophy which is probably more genetic than anything else.

Speaking of diseases that are names after the breed (rarely a good sign), this breed also gets an unusual gastrointestinal disease called Histiocytic Ulcerative Collitis, which is also called Boxer Dog Collitis. For brevity’s sake, think of it a bit like a type of IBD of Chron’s disease.

And while we’re still on the topic of diseases named after this breed, Boxer Cardiomyopathy, which is really a arrhythmogenic right ventricular cardiomyopathy that’s primarily identified in boxers, also afflicts this breed. It’s not their only heart condition though, Dilated cardiomyopathy, atrial-septal defect, subaortic stenosis and sick sinus syndrome also occur.

This is turning into a long post, isn’t it. Do you want a break? How about another gif?

Originally posted by skullvis

Okay, let’s talk some more about Boxers from a veterinary standpoint.

Boxers are prone to a couple of neurological disorders, Wobbler Syndrome is more common in larger males but degenerative myelopathy can occur in any boxer, is they live long enough to get it.

Younger boxers may develop demodex, if they’re juvenile when they do so it’s likely due to a funky immune system, which might explain a lot about this breed. Boxers that are predominantly white may also be deaf in one of both ears. It’s claimed that white boxers are more prone to cancer too, and for skin cancers this is true, but all boxers are prone to cancer. Hence the sparkly gif.

Possibly related to an interesting immune system, the breed is prone to allergies and atopy. This is a day to day annoyance on top of he life threatening/shortening conditions this breed is likely to develop.

Speaking of life threatening, the boxer dog is certainly deep chested enough to develop Gastric Dilatation Volvulus and need a trip to the emergency clinic.

And possibly the least interesting thing on this list the breed is seen relatively frequently for in the veterinary clinic is hip dysplasia.

Gosh, a long list never looks good, especially when three conditions are named after the breed.

Boxer’s also have a reputation for anaesthetic sensitivity. This is often exaggerated in breed circles, assuming the boxer in question doesn’t have one of the aforementioned heart conditions, but because they are brachephalic they have a higher vagal tone and are more sensitive to the common sedative acepromazine.

This doesn’t mean you can’t use acepromazine in boxers, only that you have to be careful with it. I will often use it at a tenth to a quarter the dose in young, nutty individuals before surgery, but some vets wont use it at all.

Can you see how living with one of these dogs would drive me nuts from a medical paranoia standpoint?

ECG: quick and dirty

I’ve had countless sessions and lectures on ECGs. I don’t know how many websites I have bookmarked, or how many times my eyes glazed over reading Dubin. I’m also terrible at cardiology. I was on my way to accepting my fate of being horrible at ECGs forever, until I had a life changing session on ECGs taught by a great ER doc. I want to post it here because it was probably the most useful thing I learned in med school, and it will stick with me for the rest of my career. 

WHEN LOOKING AT ECGs FOR THE FIRST TIME:

1. One ECG is never enough. Always get old ones for comparison. If none available, do another one. Because. One ECG is never enough. 

2. RATE. Look at the number on top of the printed ECG. It’s stupid not to use that number. Yes, you should know the rule, 300-150-100-75-60-50. People say you shouldn’t trust the machine because… well, it’s a machine, and it can make mistakes. This is true. I don’t like to look at their “diagnosis” until I have gone through it myself. But the rate is just a number. Plus you should be able to eyeball it and be able to tell if it’s tachy, brady, etc. If the machine is telling you it’s 200 and if it looks tachy, then it’s probably the right number. 
3. RHYTHM. Is there a p-wave for every QRS and a QRS for every p-wave? Is the p-wave upright in lead II and down in aVR? Good. Done. BOOM. It’s sinus rhythm. ***if you cannot clearly see the p-waves then you cannot call sinus. move on.
4. AXIS. Again, look at the number at the top of the page. If it’s between 0 and +90, then it’s normal axis. If the number isn’t provided, or if your preceptor doesn’t believe in the convenience of machines/technology, look at the QRS complex of lead I and lead II. 
  • up in lead I, up in lead II: normal axis
  • up in lead I, down in lead II: left axis deviation (most common causes are left anterior hemi block and left ventricular hypertrophy)
  • down in lead I, up in lead II: right axis deviation (most common causes are right ventricular hypertrophy…PE)
5. did someone say HYPERTROPHY?
  • look at V1
  • is the R wave tall? (greater than 7mm?) right ventricular hypertrophy.
  • is the S wave tall? (greater than 11mm?) left ventricular hypertrophy.
  6. P-waves
  • look at lead II
  • is it wide? left atrial enlargement.
  • is it tall? right atrial enlargement.
7. PR interval
  • should be between 0.12 sec and 0.2 sec (3-5 small boxes). I used to always get this interval and QRS complex (less than 0.12 sec) mixed up. Think: atria depolarizing + shit getting to ventricles is gonna take longer than ventricles depolarizing. [2 things happening] versus [1 thing happening]. [0.12 sec-0.2 sec] versus [<0.12 sec].
  • long PR interval means there’s some sort of block at the AV node. 
  • 1st deg block. PR interval is long. everything else is normal. cool. 
  • 2nd deg block
  • type I: PR interval progressively gets long. eventually a dropped QRS.
  • type II: PR interval is constant, but randomly dropped QRS. 
3rd deg block “complete block”
  • there is no association between P waves and QRS. they run separately. **QRS does NOT have to be wide. Just look for P wave/QRS complex disassociation. I sometimes get this and 2nd deg type II mixed up. The only difference I try to remember is that PR interval is constant in 2nd deg type II, but is variable in 3rd deg. 
8. QRS complex
  • narrow or wide? 
  • narrow: good. signal coming from somewhere above ventricles. 
  • wide: think BBB (bundle branch block)
  • LOOK AT V1 ONLY.
  • if the last deflection of QRS is DOWN, then it’s a left BBB
  • if the last deflection of QRS is UP, then it’s a right BBB. super easy. no more of this bunny ears crap. 
9. ST segment
  • always look from J point, and compare with the isoelectric line of T-P segment (NOT PR interval). 
  • elevated/depressed… STEMI… duh. indicates ACUTE ischemic changes. 
  • look for reciprocal changes of the heart. if ST elevation in lateral leads, could see ST depression in the septal leads. PAILS:
  • posterior up, anterior down
  • anterior up, inferior down
  • inferior up, lateral down
  • lateral up, septal down.  
LBBB can look like STEMI. How to tell?
  • disconcordant changes is normal. (QRS and STEMI on opposite sides of the isoelectric line.)
  • concordant changes is abnormal. 
  • massive discordance is abnormal. (STEMI is greater than 5mm)
  • this isn’t that important. Moving on. 
Inferior STEMI. Could right ventricle be involved? 
  • DO NOT GIVE NITRO DO NOT GIVE NITRO DO NOT GIVE NITRO.
  • order a 15 lead
  • is STE in lead III > lead II? likely RV involvement
  • INFERIOR MI? 15 LEAD NO NITRO
  • INFERIOR MI? 15 LEAD NO NITRO
  • INFERIOR MI? 15 LEAD NO NITRO
10. T waves
  • is it inverted? indicates recent ischemic changes. 
11. Q waves
  • is it significant? indicates old ischemic changes. will likely be present if followed rule number 1 of reading ECGs. (1 ECG is never enough= look at old ECGs). 
I literally go through this list of 11 points in my head when I’m reading an ECG, regardless of whether or not I have an atrial flutter jumping at my face or if I see a massive anterolateral STEMI. Obviously I needed background knowledge on ECGs and the physiology of the heart before constructing this list, but this basic checklist has been very, very useful to me so far. It might look lengthy, but it doesn’t take a lot of time at all- a patient is not likely going to have all these issues with their heart.    Anyway. I still don’t love ECGs, but it feels pretty wonderful to be able to be able to evaluate it in a systematic manner, and get the theory behind interpreting the scribbles of an ECG reading. I don’t get these moments as much as I would like to, but it’s that crosspoint where my classroom learning actually meets real-life applications that gives me happy brain-gasms for days. I love knowing things and more importantly, knowing why.

Part Two, Chapter Six: Claire.

Julia (aka Faith) has been separated from Claire in their journey thru the stones and arrived in 2007. A nurse at the hospital she is rushed to quickly takes responsibility for her, accepting her as her own child. A year passes, and it is now time for surgeons to repair the congenital defects of her heart.

You can read previous chapters here.


June, 2008; Edinburgh, Scotland.
Nurse Katie Campbell.

I stood at the observation window and watched Julia’s surgery unfold. I could hear Grannie Fiona’s knitting needles click at a steady, rapid pace from her spot behind me. There was a perfectly good chair beside her, with the same view, but my nerves wouldn’t let me sit still.

Calling in no small amount of favors, the head matron and I had gotten Julia onto the best pediatric pulmonary specialist in Scotland’s waiting list. He had moved her up to the top of his list once he heard her story and I had driven Julia here to Edinburgh to meet with him dozens of times in the fourteen months.

Today, he would repair her ventricular septal defect and replace her pulmonary valve. The surgery itself seemed to be going well. It had been years since I had assisted in an operation, but nothing the surgeon’s standard medical conversation raised any red flags.

I was thankful for Grannie Fiona’s presence, not wanting to be entirely alone but not wanting to be with someone who didn’t understand the situation. I had been granted temporary custody of Julia and we both lived with my grandmother. We had discussed the intricacies and puzzlements of Julia’s case over many a cup of tea and knew it just as well as I did. There was, for once, a guy in my life, but I hadn’t told him about Julia. She wasn’t my legal daughter, after all.

Yet.

A year had gone by and the authorities still had nothing in the form of leads. No missing children had been reported resembling her and, without a name or date of birth, they didn’t really even a firm identity to work with. She had a blood type and fingerprints, but, as toddlers weren’t the usual suspects for domestic crime, she wouldn’t be in any of the databases.

Without a documented date of birth, we had to come up with one ourselves. We finally settled on seventeen to nineteen months as her approximate age, making her birthday somewhere between the middle of July and September. July 31st had been my mother’s birthday and, as it fell within in the range, we entered that as her official birthday.

She weighed barely seven kilograms soaking wet and was a little over seventy-six centimeters tall when she arrived at Raigmore. Even though she had been roughly the size of a one year old, her teeth suggested she was a good three to six months older than that. Her mental milestones hit about the eighteen month old mark, but it was her speech that had been, and still was, a bit of a wonderment to us all.

She possessed a large vocabulary, but the kicker was that she had troubles sticking to one language. We determined she could understand three: English, Gaelic, and French. She would really only speak French if spoken to in the language, but she freely babbled in a hilarious mixture of English and Gaelic.

Who on earth were her parents? Or, in my opinion, who had they been?  

Nothing had disproved my theory that her parents were dead and it was quickly becoming accepted as fact.

Her lack of medical history had proven to be a problem in her first days at Raigmore. We hadn’t known if she had any allergies and discovered the hard way that she didn’t respond well to anesthesia. We almost lost her when we she went under for her shunt placement. This surgery posed no small amount of risk, but she wouldn’t reach adulthood without it.

A movement in the corner of the operating theater caught my eye.

“She’s back,” I commented to Grannie Fiona without turning.

The older woman cackled as she got out of her chair to come look. “I kenned she would be.”

I had told Grannie of Julia’s mother’s ghost. The apparition had appeared no less than six times in the year Julia had been in my life. Grannie wholeheartedly believed me and would often tell me her opinion on what each sighting meant. The phantom woman hadn’t spoken in her subsequent visits, only coming to comfort her child.

Grannie suddenly grabbed hold of my arm as she came up beside me, her grip vice-like.

I looked down at her, startled, “What?”

“I…” she broke off, then took a deep breath and started again. “I can see her.”

She placed a hand over her heart, as if to stop its riotous beating. Mine was behaving in much the same way. Up until this point, it seemed that I was the only one who could see her, save a few of my colleagues who professed to have felt her presence.

The figure moved closer to the operating table, coming to stand beside the anesthetist at Julia’s head. Her hand cupped it’s curve as she gently kissed the child’s brow.  She straightened then, and looked to where we stood in the observation room.

Grannie Fiona let out an audible gasp and just about fell over.

“Katie, I ken who she is!” she exclaimed.

“Who? Julia?” I asked as I steadied her. “Of course you know who she is.”

“Nae,” she exclaimed. “her mother!”

I tried to usher Grannie back to her chair, thinking her faint at the sight of the surgery, but she adamantly refused.

“I’ve met tha’ woman before,” she insisted.

“You’ve what?”

She finally tore her eyes away from the room below and stared at me, “Her name is Claire.”

8 $ commissions or donate-how-much-you-can and receive drawing/sketch (will be donated to boyfriend’s family)

As my followers probably know, about a month ago, my boyfriend and his family suffered a great loss: the death of his father in Finland, where he was working. He died in his sleep.

He was a very kind man, rough at times, mostly because he didn’t want to show weakness so he could be strong for everyone else, even though he was close to losing his mental sanity at times. These people only knew hard times, but at least they had each other. Up until now.

Apart from the emotional suffering, they were left in a horrible situation, financially speaking. My boyfriend was born with Ventricular septal defect (VSD) and his family had to pay for his medication, and later for his heart surgeries at age 7. They had to sell their house in order to pay for everything. 

They had to work hard to pay their debt, and up to this day they are still paying. Now his mother is left without her main source of support, her husband. His mother earns a ~255 $ salary, which is not enough to sustain the family: herself, and her two children, my boyfriend and his 10 year old sister.

My mother promised to help with a little donation, but she’s not a very generous woman, and a difficult person, so I think I will try to help by myself.

I therefore want to open commissions. Most of the money will be donated to his family, to help pay for the funeral, repatriation (costing 5000 euros- a fortune, basically)

I will do 8 $ commissions that will have my trademark “sketchy” lineart, and color added. Additional characters will be 8$ as well, considering the relatively low price I start with anyway. Also, if you want to donate, any sum helps, and I’ll do drawings/sketches for anything you donate as thanks.

I’ll draw a headshot or waist up by default, with a blank background. If you want something else please specify, though I’d rather keep this format- these are really busy days and full body drawings take way longer, for me at least.

Examples:

Just send me a message stating what you’re interested in. I will reply as soon as possible and will probably finish each drawing in max. ~3 days, since the funeral is on Sunday, March 12. 

Thank you.

This diagram shows how the mechanics of the heart co-ordinate with the heart sounds and the ECG (EKG).

By keeping this diagram in mind, it can make identifying murmurs much easier, by taking the pulse whilst auscultating.  

The pulse represents the maximum arterial pressure, which as you can see in the diagram occurs in between heart sounds 1 and 2. Once you have identified which heart sound is which, you can more easily identify systole, and diastole, and describe with greater accuracy the nature of a murmur if present. 

External image

Murmur Murmur

Here’s some causes of murmur patterns:

Ejection Systolic Murmurs

AorticStenosis - Ejection systolic murmur, radiates to carotids (In Aortic Sclerosis, there is no carotid radiation)

Pulmonary Stenosis  - Ejection systolic murmur which radiates to back/left scapula (may obscure second heart sound)

Atrial Septal Defect - sounds like pulmonary stenosis

Hypertrophic Cardiomyopathy - Harsh Ejection systolic murmur, palpable

Pansystolic Murmurs

Mitral Regurgitation - Best heard at apex, radiates to axilla

Tricuspid Regurgitation - Best heard at left lower sternal edge (tricuspid region) 

Ventricular Septal Defect - Best heard at left sternal edge

Early Diastolic Murmurs

Aortic Regurgitation - best heart at left sternal edge, in expiration, with patient leaning forward

(Rarely) Pulmonary Regurgitation

Mid-Diastolic Murmurs

Usually Mitral Stenosis - Best heard with Bell of stethescope at apex, with patient rolled to left

Rarely Tricuspid stenosis - sounds simliar to Mitral Stenosis

Continuous Murmur - referred to as a ‘machinery murmur’, although I don’t think anyone knows what machine it sounds like.

Patent Ductus Arteriosus - rare in adults. Best heard over upper left sternal border, radiates to back/left scapula

anonymous asked:

Dog breeds: Samoyeds? <3

In future it would be great if these requests came as a sentence instead of a dot point, just so they make more sense for newcomers.

These posts are about the breed from a veterinary viewpoint as seen in clinical practice, i.e. the problems we are faced with. It’s not the be-all and end-all of the breed and is not to make a judgement about whether the breed is right for you. If you are asking for an opinion about these animals in a veterinary setting, that is what you will get. It’s not going to be all sunshine and cupcakes, and is not intended as a personal insult against your favorite breed. This is general advice for what is common, often with a scientific consensus but sometimes based on personal experiences, and is not a guarantee of what your dog is going to encounter in their life. 

Originally posted by wintersfluffyland

Samoyed are big, white, super fluffy dogs with a double coat. They’re not very common because keeping the dog white is something of a challenge, and the general trend in suburbia is to keep smaller and smaller breeds of dog.

Hip Dysplasia is an issue in this breed, and breeders should routinely be screening for it.

A genetic kidney disease, Hereditary Nephritis, is an X-linked disease resulting in kidney failure early in life for affected animals. Males are affected more severely than carrier females, but a female with two copies of the gene will be just as badly affected. Responsible breeders should be screening their dogs, because carrier females have a 50% chance of any male offspring inheriting this condition.

The breed is known to develop various heart conditions, including subaortic stenosis, pulmonic stenosis and atrial septal defect so you can’t assume which cardiac condition a dog has, and a heart ultrasound should always be considered.

Samoyeds are also known to get Progressive Retinal Atrophy, cataracts and glaucoma. They also seem to get UV associated dermatoses more common than other breeds, at least locally, but I kind of suspect this is in spitx type breeds in general, as these dogs are certainly not alone.

The coat maintenance of these dogs is their most frequent issue. They certainly look gorgeous and fluffy, but nine times out of ten when I see one of these dogs they’re pretty on the surface, but there coat is severely matted down to the skin. Often these dogs end up needing to be shaved, as much as that is a shame, because their cat has matted into one big fleece. This often results in seriously manky hot spots which can get very large and painful.

The One With The Witch

Pairing: Alec Lightwood x Reader

Summary: In his desperation, Alec seeks out a witch to spell him so he can see Jace, even if it is just a hallucination, but doesn’t anticipate you risking your life to help him nor the attachment he feels towards you immediately after. 

MASTERLIST, MOBILE MASTERLIST (you can like it and save it for later!)

———————————————————————————————————-

“What exactly are you asking me?” Meliorn asks, leaning back in his chair. He studies Alec intently, watching him pace back and forth.

 “I need to see him,” Alec mumbles.

 “I was under the impression that Jace had… disappeared. That you can’t see him through your parabatai bond,” Meliorn states.

 “Yes, but I need to see him – I –“ he inhales sharply, “I know there are ways you can help.”

 “I’m not following,” Meliorn frowns.

 “Drugs,” Alec snaps, “Drugs that make me see him.”

 “Oh Alec,” Meliorn sighs, “I’m afraid party drugs that downworlders use don’t possess the effects you describe but-“

 “But?” Alec asks eagerly.

 “But there are potions, witch’s spells, herbs – but there’s no accuracy to what you see. They’re just illusions. It won’t help you.”

 “I just need to see him,” Alec mumbles.

 “Then you need to find yourself a witch… or warlock. Have you asked Magnus?”

 “Magnus wouldn’t help with something like this,” Alec sighs, “Know any witches?”

 Meliorn nods slowly, “I should warn you… Y/N is a bit prickly.”


 The whole day you’d been haunted by the dark haired boy standing in the corner of every room you walked into. Not like you weren’t used to having Shadowhunters drop in on you to make sure you weren’t torturing people but being distracted by his pacing in the middle of a surgery when no one else could see him was pretty problematic.

 “Hey,” you finally snap, dragging Alec to your office when you find him standing outside the bathroom. Once you lock your door, you turn to face him, “You have ten seconds to tell me what the hell you want.”

 “I’m Alec Lightwood,” he says.

 You roll your eyes, “Of course you are. I’m surprised they sent one of Maryse’s kids to check on me – aren’t you guys a big deal?” you scoff, “Look, as you can see I’m saving Mundane lives not killing them. I’m trying to do good which is kind of hard when you’re standing next to me during a Septal Myectomy!”

 “A what?” Alec frowns. He waves a hand in the air, “Look, far be it for me to understand why a powerful witch like you would want to live in the mundane world as a surgeon,” he scoffs, “But I’m not here to check up on you. I need you do to something for me.”

 “You… need a favour?” you cock a brow up, smirking, “Well, that’s rich.”

 “Look, I don’t know what problems you have with my family but I assure you I played no part in them.”

 “You’re a Lightwood – you’ve already played your part in the torture and mistreatment of downworlders.” You open a bottle of bourbon and pour him a glass, waiting for him to take it before continuing.

 “Still, I’m curious to know what someone like you would need from me,” you inhale slowly, “You’re not dying are you?”

 “No, I don’t need surgery if that’s what you’re asking me. I need – I need drugs.”

 You bite back laughter, “You’re asking me to give you drugs? So you can get high?” you tilt your head and shoot him a funny look, “There are plenty of drugs in the Shadow World that would be far more effective on a Shadowhunter than mundane drugs from a hospital,” you explain pointedly.

 “I don’t want mundane drugs,” he says stiffly, “I need you to make me like a witchy potion or spell me.”

 “’A witchy potion’,” you repeat, chuckling, “Shadowhunters really are stupid.”

 “Why?”

 Suddenly your expression is serious, “Because you come here, asking me to curse you – to drug you using witchcraft when you know I can’t. It’s in the accords.”

 “You’re not breaking any rules if I’m asking willingly,” he insists.

 “Get out,” you spit, “You Shadowhunters are so entitled. Making and breaking the rules. I have a good life and I’ve worked hard for it and I’m not about to throw it away so you can get a fix,” you say, shoving him out the door, “If I see you here again, I’ll kill you.”

 “Wait, wait, wait,” he pleads, holding the door open as you push against it, “I’m not looking for a fix. My parabatai, Jace – Valentine took him. I just want to see him again, even in a hallucination. I need to see him alive and well to keep me going, I just –“ he chokes, his eyes welling up, “I can’t keep going with this weight on my chest that he might be dead.”

 “Can’t you use your parabatai link?”

 “I can’t see him. It’s like he’s disappeared.”

You sigh. The most likely explanation for that was that he was probably dead. Still, seeing Alec crying and desperately seeking your help somehow appealed to your softer side.

 “Only once,” you say, “I finish at 11. I only have a few hours before I have to be back. I’ll meet you in the parking garage.”

 “Thankyou,” he chokes, throwing his arms around you. His height and build almost sent you tumbling to the floor. You struggle to stand properly and push him away, “Don’t hug me,” you mumble, patting his arm with an awkward smile.

 “Hey,” he mumbles in the doorway, “Aren’t you a little young to be a surgeon?”

 “Witches and Warlocks age slowly,” you say, “I may look younger than you but the chances are, I’m not.”

 “I doubt it,” he chuckles, “How old are you?”

 “Goodbye Alec,” you say, pushing him out and shutting the door.

 As he turns around to protest, the door slams in his face, “Meliorn wasn’t kidding about you being prickly,” he mumbles to himself.


 Hospital life kept you busy but you always tried to find time to practice witchcraft – falling out of touch with it was never a good idea. It existed within you, in your blood, in your mind – you could never outrun it. So you learned to control it.

 But with dark magic, there was always a chance of losing control.

 “Give me your hands,” you say, holding yours out. You feel Goosebumps rise on your skin at the warmth of his touch.

 Alec turns his head, examining your flat. It was very cottagey, timber floors and a fire place – the candles filling the room with a warm vanilla scent.

 “I always thought witches would live in like medieval castles,” he says.

 “Bit hard to find one of those in Manhattan,” you scoff, “Concentrate.”

 He smiles, closing his eyes and slumping slightly as he relaxes. He listens to you mumble incantations. He could feel your hands tightening around his and he winces slightly – it felt like you were crushing his bones.

 “Ah- are you sure you’re doing this right?” he asks, grimacing until his eyes flutter open. He pulls his hands out of yours, examining the deep, purple bruises.

 “Y/N?” he waves a hand in your face. Your eyes were open but you don’t flinch.

 “She can’t hear you now – you’re in a whole different realm,” Jace’s voice comes from behind him

“Jace,” Alec sighs, pulling him into a hug, “I’m so glad you’re okay.”

 “Well, that’s not entirely true. I’m just a hallucination. A figment of your imagination,” Jace laughs.

 “I’m going to find you,” Alec says sternly, “I’m going to bring you back.”

 “I don’t doubt that,” Jace says, “But you can’t do that if your mind is over here with me. You’re hurting yourself-“ he looks over Alec’s shoulder, “And her.”

 Alec looks at you, shaking slightly with blood dripping from your nose. He could hear you whimpering.

 “What’s happening to her?”

 “This is dark magic. Forbidden magic. And to perform it on a Shadowhunter when it goes against the accords has it’s price,” Jace explains, turning Alec to face him, “Go back to the real world to find me – what you find here will only bring you short term comfort.”

 Alec nods, pulling Jace into one last hug. As he pulls away and turns back, reaching for your hands, Jace grabs his arm.

 “And stay with her,” Jace adds, “She’ll help you through this and she’ll help you find me,” he says, winking.

 Alec nudges him playfully, rolling his eyes before closing them and taking your hands again. When he opens them, Jace is gone but you’re still there, shaking, about to pass out.

 “Whoa,” he mumbles, holding you up by the shoulders as you begin to collapse. He scoops you up in his arms and lays you down on your couch.

 You’re out cold for hours and when you come to, he’s still by your side.

 “Shit, what’s the time?” you shout, shooting straight up.

 “Don’t worry, according to your phone you’ve still got another 40 minutes before you have to be at work,” he says.

 “Oh, good,” you sigh in relief, lying back down.

 “Why did you help me?” he asks, “Jace said it could’ve killed you.”

 “Don’t flatter yourself,” you chuckle, “I didn’t know it’d take such a big toll.”

 That was a lie but you weren’t about to admit that him fluttering his long eyelashes at you got the drop on you nor were you going to admit that you thought you could handle it when you clearly couldn’t.

 “I doubt that,” he gives you a small smile, “Seems to me like you took a risk for me.”

 “And why would I do that?” you leer, turning away from him.

 “I don’t know,” he shrugs, his voice teasing.

 “Well, I’d better get going,” you say, standing up and pulling on a coat, “I hope you find what you’re looking for. I won’t be able to do that again, Alec.”

 “Thankyou,” he says, walking beside you to the front door. You wait for him to go out but he lingers, leaning against the frame.

 “What are you doing?” you ask, frowning.

 “I found what I’m looking for,” he says with a cheeky grin.

 “What?”

 “Right here,” he says, walking back inside and sitting on your couch, “I’ll be here when you get back,” he sighs, getting comfortable as he stretches across it, cupping his hands behind his neck for support.

 You should’ve been mad or annoyed but suddenly having such a tall, and let’s admit – handsome - Shadowhunter in your living room made it seem less lonely.

 “There’s ingredients for lasagne in the fridge,” you call out. He shoots up from the couch, rushing into the kitchen.

 “I’m on it!” he calls out.

Another appt. and ultrasound today. Had a little scare when our doctor noted, for the first time in the 34+ weeks of our pregnancy, that our son has a Ventricular Septal Defect. A small one. So there is a little hole creating blood flow issues between two ventricles in his heart.

Our doctor doesn’t seem terribly concerned and says that, as small as it is, it’s unlikely it will cause any long term issues. In fact, a VSD hole can pretty much close up after birth as everything continues to grow.

Our other concern is his kidneys, which are enlarged but just within normal limits. This could mean bladder issues after birth or even hydronephrosis (remember when I posted about the two excruciating nights I spent in the ER? Yeah, that’s hydronephrosis).

For now, though, all we can do it wait. Both conditions require observation after delivery, so nothing can be done until then. The doctor seems confident that neither of these conditions warrants a panic attack and he’s been doing this for 38 years, so I think the healthiest thing we can do for ourselves and for baby boy is to stay optimistic. :)

Baby girl is just peachy.

Where Milo Lives with ASD

So I formulated an au where Milo lives with an atrial septal defect since he was born premature.

Because of his having to go without overworking himself and worsening his heart, dodging Murphy’s law has its complications - Especially when it has to be run away from to avoid getting hurt.

Got a couple HCs for this but I’m gonna need your thoughts and opinions before I post them. Nothing too serious though. Just some bouncy Milo and really helpful family and friends… Oh and dog of course :3

What do you guys think?

2

The dawn of heart surgery.

Clarence Walton Lillehei was known as the “father of open heart surgery”. Indeed, hardly any other cardiac surgeon has introduced a greater number of innovative techniques and concepts.

During his career, Dr Lillehei focused his efforts on cardiac surgery, particularly the development of open heart operations. The difficulty of operating on a beating heart and the hypoperfusion of the vital organs were serious and frequent complications of heart surgery. In 1953, Dr John Gibbon of Philadelphia successfully closed an atrial septal defect using a complex screen oxygenator and roller pumps. However, the mortality of open heart surgery remained high, mainly because of oxygenator-related problems, and many surgeons despaired of ever being able to correct complex intracardiac defects. 

This situation was changed in March 1954 when Dr Lillehei and his associates—Morley Cohen, Herb Warden, and Richard Varco— used controlled cross-circulation to correct a ventricular septal defect in an 11-year-old boy. The boy’s anesthetized father served as the oxygenator. Blood flow was routed from the patient’s caval system to the father’s femoral vein and lungs, where it was oxygenated and then returned to the patient’s carotid artery. The cardiac defect was repaired with a total pump time of 19 minutes. Over the ensuing 15 months, Lillehei operated on 45 patients with otherwise irreparable complex interventricular defects; most of these patients were less than 2 years old. Although cross-circulation was a major advance, it was not adopted for widespread use because it posed a serious risk to the “donor”. Nevertheless, this method paved the way for the open heart surgery era.

That same year, Dr Richard A. DeWall and Dr Lillehei introduced the first clinically successful bubble oxygenator, which remained the standard for extracorporeal circulation until the late 1970s. Dr Lillehei also helped pioneer hemodilution and moderate hypothermia techniques for open heart surgery. 

alphabet soup: disease edition

Here are a few commonly used medical abbreviations:

AAA - abdominal aortic aneurysm
ACS - acute coronary syndrome
ADHD - attention-deficit/hyperactivity disorder
AIDS - acquired immunodeficiency syndrome
AKI - acute kidney injury
ALS - amyotrophic lateral sclerosis aka Lou Gehrig’s disease
ARDS - acute respiratory distress syndrome
ASD - atrial septal defect
AVM - arteriovenous malformation
BPH - benign prostatic hyperplasia, now known as LUTS
BV - bacterial vaginosis
CAD (s/p PCI/CABG) - coronary artery disease (status post percutaneous coronary intervention/coronary artery bypass grafting)
CHF - congestive heart failure
CKDI-IV - chronic kidney disease (stage I-IV)
COPD (on HOT) - chronic obstructive pulmonary disease (on home oxygen therapy)
CVA - cerebrovascular accident aka stroke
DDD - degenerative disc disease
DJD - degenerative joint disease
DLD - dyslipidemia aka HLD
DMD - Duchenne Muscular Dystrophy
DMI aka IDDM - Diabetes mellitus Type I aka Insulin-Dependent Diabetes mellitus, previously known as Juvenile-onset Diabetes
DMII aka NIDDM - Diabetes mellitus Type II aka Non-Insulin-Dependent Diabetes mellitus, previously known as Adult-onset Diabetes
DT - delirium tremens
DVT - deep vein thrombosis
ED - erectile dysfunction
ESRD on HD - end stage renal disease on hemodialysis
GAD - general anxiety disorder
GERD - gastroesophageal reflux disease
GIB - gastrointestinal bleed
GVHD - graft vs host disease
HIV - human immunodeficiency virus
HLD - hyperlipidemia aka DLD
HPV - human papillovirus
HTN - hypertension
HUS - hemolytic uremic syndrome
IBD - irritable bowel disease
IBS - irritable bowel syndrome
ICH - intracranial hemorrhage
IDDM - see DMI
ITP - idiopathic thrombocytopenic purpura
LEMS - Lambert-Eaton myasthenic syndrome
LGIB - lower gastrointestinal bleed
LUTS - lower urinary tract symptoms
MAC - Mycobacterium avium complex
MDD - major depressive disorder
MM - multiple myeloma
MS - multiple sclerosis
NIDDM - see DMII
NPH - normal pressure hydrocephalus
NSTEMI - non-ST segment elevation myocardial infarction
OA - osteoarthritis
OCD - obsessive compulsive disorder
OHS - obesity hypoventilation syndrome aka Pickwickian Syndrome
OSA (on BiPAP/CPAP) - obstructive sleep apnea (on bilevel positive airway pressure/continuous positive airway pressure machine)
pAF (on AC) - paroxysmal atrial fibrillation (on anticoagulation)
PBC - primary biliary cirrhosis
PE - pulmonary embolism
RA - Rheumatoid arthritis
SARS - severe acute respiratory syndrome
SLE - systemic lupus erythematosis
STEMI - ST-segment elevation myocardial infarction aka ischemic heart attack
STD - sexually transmitted disease
TB - Tuberculosis
TBI - traumatic brain injury
TIA - transient ischemic attack aka stroke symptoms that last <24 hours
TMJ - temporomandibular joint disorder
TTP - thrombotic thrombocytopenic purpura
UC - ulcerative colitis
UGIB - upper gastrointestinal bleed
URI - upper respiratory tract infection
UTI - urinary tract infection
VSD - ventricular septal defect

TRANSPOSITION OF THE GREAT ARTERIES

Transposition of the great arteries is a congenital heart defect in which the pulmonary artery and aorta are in reverse positions. The pulmonary artery, which should normally arise from the right ventricle, arises from the left while the aorta, which should normally arise from the left ventricle, arises from the right. This results in parallel circulation. Blood flows from the aorta to the body to the right ventricle back to the aorta, and from the left ventricle to the pulmonary artery to the lungs back to the left ventricle. Oxygenated blood and deoxygenated blood never mix, and deoxygenated blood is continuously sent out the body. 

How is the baby alive, then??

The patent ductus arterious! The PDA is a connection between the aorta and pulmonary artery that is normally present in all babies, but closes shortly after birth. A medication called prostaglandin can be administered to keep this duct open. The blood is then able to mix, allowing for some oxygen to reach the cells of the body. In most babies, though, this shunt is not enough. An ASD (atrial septal defect, or hole between the atria) is usually created via atrial septostomy either at the bedside or in the cath lab to allow for greater mixing. Since the blood is mixed, babies will have decreased sats.

Ultimately, an arterial switch operation will need to be performed to allow for proper circulation.

bbc.com
The Bolivian women who knit parts for hearts - BBC News
The Aymara women of Bolivia are using their centuries-old knitting and weaving skills to make parts to help children with holes in their hearts.

The indigenous Aymara women have centuries of experience of knitting and weaving distinctive woollen hats, sweaters and blankets.

Now, they are applying their expertise to a hi-tech medical product - which is used to seal up a “hole in the heart” which some babies are born with.

“We are very happy, we are doing something for someone so they can live,” says knitter Daniela Mendoza, who weaves the tiny device in a special “clean room”.

It takes her about two hours to make the Nit Occlud device which was designed by cardiologist Franz Freudenthal. He set up his clinic in La Paz to help children born with heart problems and so far he has saved hundreds of lives.

The device, known as an occluder, looks similar to a top hat and is used to block the hole in the patient’s heart.

Most standard occluders are made on an industrial scale - but Freduenthal’s version is so small and intricate that it’s technically tricky to mass produce.

So he enlisted an army of Bolivia’s traditional craft knitters to make them by hand.

In the early days he tested the first prototypes on sheep with heart problems. He’s since successfully used them on hundreds of children and now exports his new inventions all over the world.

“The most important thing is that we try to get really really simple solutions for complex problems,” Dr Freudenthal told the BBC.

Te amo con mi cerebro, con mi sistema límbico; con mi hipotálamo, con mi circunvolución del cingulo, con mi área septal, con mi amígdala cerebral y con mi corteza pre frontal, también te amo con otras partes cerebrales, pero principalmente te amo y te deseo con mi ínsula y con mi núcleo estriado, yo te amo gracias a mi dopamina y norepinefrina, te amo gracias a mi oxitocina y vasopresina, te amo y te deseo con mi cerebro amor.
—  Jonathan Palacios, Amor neurológico.
2

Tetralogy of Fallot.

Tetralogy of Fallot (TOF) is a congenital heart defect which is classically understood to involve abnormalities of the heart. It is the most common cyanotic heart defect, and the most common cause of blue baby syndrome.

As such, by definition, it involves four heart malformations which present together:

  • Pulmonary Infundibular Stenosis: A narrowing of the right ventricular outflow tract. It can occur at the pulmonary valve (valvular stenosis) or just below the pulmonary valve (infundibular stenosis).
  • Overriding aorta: Aorta is situated above the ventricular septal defect and connected to both the right and the left ventricle.
  • Ventricular septal defect (VSD): A hole between the two bottom chambers (ventricles) of the heart.
  • Right ventricular hypertrophy: The right ventricle is more muscular than normal, causing a characteristic boot-shaped (coeur-en-sabot) appearance as seen by chest X-ray. 

Signs and symptoms: Tetralogy of Fallot results in low oxygenation of blood due to the mixing of oxygenated and deoxygenated blood in the left ventricle via the ventricular septal defect (VSD) and preferential flow of the mixed blood from both ventricles through the aorta because of the obstruction to flow through the pulmonary valve. This is known as a right-to-left shunt. The primary symptom is low blood oxygen saturation with or without cyanosis from birth or developing in the first year of life. Other symptoms include a heart murmur which may range from almost imperceptible to very loud, difficulty in feeding, failure to gain weight, retarded growth and physical development, dyspnea on exertion, clubbing of the fingers and toes, and polycythemia. Digital clubbing or watch-glass nails with cyanotic nail beds is common in adults with tetralogy of Fallot (2nd picture).

Cocaine really is a terrible drug. Here is some good info explaining why:

Cocaine every weekend is considered heavy use (more than 50x a year = heavy use), which is about 20% of cocaine users, and also similar to the amount of people who would be classified as having cocaine use disorder (addiction).

About 80% of the time it’s taken it’s going to be tainted with levamisole, a parasitic worm infection drug.

You’re 20x more likely to die of a stroke while high on cocaine, and if you’re using alcohol too (like most people do when using cocaine) that number is 100x. For the next week after using (so all the time for you) you’re 10x more likely to die of a stroke.

If it’s cut with metoprolol (a beta-blocking cardiac drug) your chances of having coronary vasospasm are much higher than with cocaine alone. About 5-10% of cocaine is cut with metoprolol.

If it’s cut with diltiazem (actually heart protective while on cocaine, unlike metoprolol) and you have a cardiac abnormality like wolf-parkinson-white syndrome, your first line might kill you. About 5-10% of cocaine is cut with diltiazem (slightly higher than metoprolol).

Nasal septal perforation happens to everybody, cocaine is a profound vasoconstrictor too. You’ll eventually end up with akathisia, increased impulsivity, permanent derangement of your opioid receptors, permanent derangement of your D2/D3 dopamine receptors, worse gambling performance, worse delayed gratification. You’ll basically never be able to feel as happy as you did while you were on cocaine for the rest of your life. Some of these cognitive deficits disappear after about 2 years of discontinuing, most of them disappear after 8+ years of abstinence, but some of them have been shown to be present even after 10+ years of quitting. Some of these changes have probably already happened to “your friend” and are irreversible, if you’re asking this question now.

Increased predilection for high risk behaviours, this mostly goes away after years of abstinence, but it persist to some degree. Cocaine users are much more likely than the average person to have transmissible diseases. That’s why cocaine use + blood donations don’t mix. Plus with the average purity of cocaine being about 40% in the US (closer to 60% in border towns by Texas) you have no idea what other drugs you’re ingesting too (definitely levamisole, maybe cetirizine, diltiazem, metoprolol, probably caffeine and ephedrine)

If you’re sharing bills/straws you will end up getting whatever infection someone has eventually (cocaine use is a little known source of Hep C infection, it’s not nearly as common as from heroin/injecting drugs even like cocaine, but snorting coke is a risk factor too).

Cocaine induced ischemia in the hands/feet/bowels (cocaine ischemia can affect the stomach), permanent cardiac/brain damage. I’ve seen multiple small infarcts/brain stem lesions on people’s imaging scans (they were pointed out to me by the radiologists) on even recreational cocaine users (10-15x a year for a decade) in their 20s 30s. You give yourself mini-strokes all the time with cocaine. Haven’t seen focal band necrosis on the heart (you scar your heart and it dies, but it’s only small ilttle bits and pieces of it) but that’s because I never took a pathology elective, apparently it’s a very common finding in even young regular (50x+/year) cocaine abusers.

Cocaine + alcohol = cocaethylene which is more toxic to the heart and liver than either alone. I think the effects in literature might have been overstated, but it’s definitely true that it’s more harmful, just probably not 5x more harmful or whatever. Additive with some synergistic effect.

MUCH higher risk of suicide. Basically using cocaine is like inducing the mania component of bipolar disorder, except it’s much worse on your body (because of the tachycardia, vasoconstriction, and hypertension induced by cocaine), so when you come down you wanna kill yourself.

Every year of cocaine abuse ages your brain at double the rate of average. So at once a week use for 10 years, (lets say between 20-30) your brain age will end up being 40, but you won’t be less intelligent or anything because of it, just slower at processing things. It causes permanent changes in short term memory and brain atrophy (gray matter) that’s irreversible too, and not entirely similar to normal aging, but the “normal aging” part of brain development doubles too, is what I’m saying.

Double Outlet Right Ventricle

Double Outlet Right Ventricle (DORV) is a congenital cardiac anomaly in which both the pulmonary artery and aorta arise from the right ventricle. In a normal heart, only the pulmonary artery connects here while the aorta connects to the left ventricle.

DORV is typically associated with a ventricular septal defect (VSD, or a hole between the ventricles). Transposition of the Great Arteries (TGA, or when the pulmonary artery and aorta are in reverse locations), pulmonary stenosis/atresia (abnormalities with the pulmonary valve that prevent or decrease the flow of blood into the pulmonary artery), and corarctation of the aorta (a narrowing of the aorta) can also frequently occur with this defect.

The VSD allows oxygenated and de-oxygenated blood to mix. This mixed blood is what is carried out to the body. Because of this, you can expect a patient with this condition to have decreased oxygen saturations (usually in the mid-70s to 80s). 

Surgical repair is necessary, but the exact procedure can vary greatly between patients. The approach will depend on the location of the VSD, location of the great arteries, and how developed the ventricles are. Some patients will be able to have a two ventricle repair, while others will require a single ventricle repair.

so, my mom’s best friend’s husband is a scanner like me (scanning hearts, arteries, & veins using ultrasound) & he let me scan patients at his clinic & it was so awesome, I saw a bubble study too (sometimes people have a shunt, aka hole in their heart, such as an atrial septal defect & these bubbles go into the right side of the heart & if you see it on the left side that means there’s a shunt) I learned v cool things & noticed what it is i need to review, so yay improving myself ♡

Open heart surgery VIDEO

Heart surgery can be a simple or complex procedure. There are a variety different ways it can be done, for a plethora a reasons. You can receive open heart surgery or you can just have a catheter places up one of your groan area to be treated.

Today, is a video of a rare atrial septal aneurysm. It’s a bit artsy, but interesting to watch them go through all the steps.

Article by: Meddaily

i’m sick of your fucking poetry.
i don’t want another metaphor: hearts breaking
like the dawn. the next time you say “broken" 
it’s gonna be somebody’s fist and somebody’s teeth.
i’m trying to be serious and you’re thinking:
it tasted like lighting a match on my teeth,
it tasted like the meat of my own tongue.
i’m trying to explain congenital heart
disease, atrial septal defects,
and all you’re thinking is somewhere in my chest
sits an adder stone, you’re thinking
i’ve got a black hole the size of a fist
perched in my ribcage like a songbird.
talk to dirty to me, you say, tell me what it was
that fucked you up. i am sick
of you trying to catalogue these hurts,
to fit them into similes. if you love me
it’s the way audubon loves birds.
if you love me it’s the way poets
love poetry and i am sick
of being your poem. and there you go
again, complaining about the blood
under your nails when it doesn’t even belong
to you. so write me another sob story.
play the violin, play the victim.
but stop writing poems about poems.
stop pressing your hands to the wound.
"runoti” means both to speak and to cut,
you explain, but i’m not listening anymore:
there is a hole in my chest that you need
to stop trying to fill with metaphors.
there’s a hole in my chest but it’s mine, baby,
it’s all i got.
—  s.s., adder stone