Keeping Starbucks in business

For those of us lucky enough to be in summer classes, today is the first day of finals week. For those of you that have completed the collegiate phase of your life, you'll remeber this was the week you didn't get to drink. For me, this breaks down to: Neurochem tonight, Cellular Biology Wed night, Chem lab II Thurs morning and Clinical Research Thurs afternoon. Three days off... then my brand-spanking-super-fantastic new full-time job kicks off.

Because my brain is completely full and there's nothing I can write to make arcuate nucleus/paraventricular nucleus control over feeding behavior interesting to someone not already interested in neurochemisty... I thought it would be amusing to analyse the behaviors of post-bacs studying for finals.

# of libraries open on Sundays in University City: 1
# of post-bacs I spied from my one little chair in said library: 11
# of them who brought communal home-made gingersnaps: 1
# who bought snacks/lunch from Wawa: 11
# places besides wawa to get food in the vicinity: 0
# strange people with suitcases and smelly curry: 1 (not a post-bac)
# of med students in the medical library: 1
# undergrad TAs called into the library: 1
# cups of coffee consumed by post-bacs that day: lost count
# ice creams the girl I studied with ate: 2
# ice creams I ate: 0 (really!)
# text messages I sent while "studying": 23
# "quickies" I had between the stacks for stress relief: 0
# times I had sex that day/night for stress relief: none of your business ;)

Good luck everyone!

Screwdriver + Chest = Pericardial Centesis

A day of teachable moments in the ER...

A patient was helicoptered into our ER from another ER (why is not exactly clear) with a stab wound to the left chest caused by a screwdriver. The patient had marked jugular distension (bulging neck veins), extreme hypotension (ie, no blood pressure), and muffled heart sounds. What does this (Beck's triad) of symptoms indicate? Cardiac tampenade!

The patient was bleeding into the sac around his heart (the pericardium) and this was putting pressure on the heart itself. Since there is no space around the heart, it cannot expand when filling with blood, limiting the volume of blood that can enter the ventricle. This means less blood is being pushed out with each contraction (decreased stroke volume and thus low blood pressure) and a build of of venous blood in the neck (think of a traffic jam in your superior vena cava).

To treat this particularly life threatening issue, the blood is drained from the pericardium while stabilizing the patient to get them to the OR. This draining procedure is the pericardial centesis and they performed it on the patient twice.

Had the patient been registering a blood pressure, we probably also would have seen pulsus paradoxus: a 10 point drop is systolic (top number- ventricular contraction) blood pressure on inhalation (breathing in). When you breathe in you are actually expanding your chest to create a highly negative pressure (4x less that the atmosphere) inside your lungs. This pulls air into your lungs (goes from high pressure to low) but it also helps pull thoracic blood (blood in your torso) back towards your heart. The thing is, if your heart can't expand because your chest is filled with blood, then filling the right side with venous blood leaves very little room on the right side for oxygenated blood coming from your lungs. Thus, even less blood is pushed out of the left side on contraction and you have an even lower blood pressure.

The trouble with working in the ER is that you don't "follow" your patients. He was alive when he got to the OR, I have no idea if he still is.

Real Time Blogging from the ER

18:05 shift starts and all I have to start off with is three domestic violence screenings. In the process though I meet a very friendly third year med student.
18:30 checking the board for patients when a dr. comes and shows me a right wrist fracture on x-ray
19:30 finally consented a man for the cardiac study after trying to wake him for half an hour. Had to bang on the bed and even then he kept falling asleep in the middle of sentences. Chronic cocaine abuse, but seems to think quick highly of himself. Seems to think I would be fawning all over him if I'd met him in the hospital..hah!
19:50 dr. showed me cardiac man's EKG, unremarkable.
20:02 finally get to sit down for a minute to eat the food we ordered. Chicken kabobs with pita and tabolae salad.
20:25 processed cardiac man's bloods. Got 26 crio vials from the four tubes, takes about an hr to get through.
21:30 another round of domestic violence screenings to do...I've got seven so far, that's how many you generally get in a whole shift. This time I did one with the docs in the room on a 17 yr old pregnant girl. She's not the youngest pregnant I've seen either, record sits at 15.
21:41 Sophie whips out the MnMs - she's always got goodies :)
22:00 cardiac man is asking for even more juice (carton #6?) and is now claiming to be a singer/songwriter/politician/filmaker. Annoyed that dr won't give him Percocet so asking for a new dr. No doctor here will prescribe it (note in his file) so med student pretends to be a second opinion and denies him Percocet.
22:30 doing a domestic violence screening while playing swords with a woman's son. Apparently McDonalds now has inflatible swords for Pirates of the Carribean.
22:40 played patient advocate for some patients whose nurses had gotten busy; it's one of the side jobs, being able to help people by making sure they get the attention they need.
22:45 trauma alert went off for an incoming assault victim. ETA, less than 5 mins.
23:30 assault was pretty nasty - hit with bricks and planks by multiple assailants while trying to protect his father. Swollen and cut all over, still in his collar.
23:35 cardiac man is being transferred to a rehab facility because "to have a serious music career you really have to be clean. It's the Beatles, they brought all the drugs to the music. That's why they killed John Lennon, they were afraid people would follow him over the President."
23:55 wrapping up the paperwork and cleaning up the desk. Quick chat with the med students (they're pretty and have more time to be social). Should be out of here on time tonight, which will be a welcome change

Nothing to do with medicene

Since so much of my (recently sparing) writing involves the hospital or class or some form of medical research, I thought I'd take a moment and reflect on the small corner of my life that is everything else (aka a life).

My parents trekked out here from LA to come and spent the fourth with me. I haven't seen them since last October, so the visit was welcome and singularly well-timed since I had just completed my midterms. They brought a heat wave with them, which was particularly tough on my mother when combined with the humidity so we needed some air-conditioned time. This was easily solved with a few boxes of hair dye - transforming me into a brunette became my mother's two-day project. We managed to find great seats for the fireworks, though we were less than impressed with the Lionel Richie concert (it's elevator, put-on-hold music). We also found the best Indian food this side of well, the globe, at Cafe Spice. Yum.

I have landed myself the coolest job ever as a clinical research associate in pediatric neurology where I'll be working on pediatric stroke and other cerebral vascular disorders. I'm really excited about it and with some luck and diligence I might be celebrating publication sometime in the next year and a half.

I've reached the six month mark with my "significant other" - a time span that simaltaneously feels like an era and a second. Next milestone, his birthday. Thankfully I have until September to think and rethink my gift selection.

My brother is off galavanting through Italy and my friends have all migrated (or are migrating to) California. I have been feeling the call of the West lately... though I shall have to put CA on hold until at least Christmas.

Right, I'm out of interesting tidbits... time to work/watch Netflix movies... fill in procrastinating activity here.

MoyaMoya

MoyaMoya is a cerebral vacular disease occuring most frequenting in Asian populations involving vascular occlusion (blockage) in the basal ganglia. On some occasions the brain grows many small vessels around the occlusion in an attempt to compensate for the decrease in blood flow, while other cases require cranial surgery.

This is one of the diseases I'm becomming familiar with now that I'm working in pediatric neurology research (yay!). The image below is from Hawaii and shows the occlusions fairly well. The image work I'm doing actually produces 4-D scans of the vascualture and allows us to calculate blood flow and velocity to different regions of the brain.



On a different note, we had a 186kg woman in the ER the other day. That's 410lbs. That's substantial.

Bella the MG dog

When we covered Acetylcholine (Ach) in neurochem one of the disorders we discussed was myasthenia gravis (MG). MG is an autoimmune disorder in which your body produces antibodies that block the Ach receptors of the neuromuscular junction. What this means is that when a nerve cell releases Ach to initiate muscle contraction, the muscle cannot receive the signal. The most prominant symptom of the disease is catalepsy (the inability to initiate voluntary movement).

The video (click here) shows Bella, a small dog, who has MG. Initially she cannot stand up and when the vet administers a blink test, she shows no reaction. The vet gives Bella some Edrophonium chloride, a drug that temporarily increases Ach tone. Subsequently, Bella can be seen running and reacting to the blink test until the medication wears off (it's called a Tensilon test). Bella is now on Pyridostigmine, a longer acting drug that also increases Ach tone, and has 75% of a normal dog's ability.