My mother died last Tuesday. She had her coronary bypass surgery just one week before that day. It was during her CABG that she had her strokes. Yes, strokes, plural. She was one of those 1.5% who suffer macroemboli cerebral strokes during coronary bypass surgery.
I went looking for information on it earlier this week. I went through my training without ever seeing this complication. Like everyone, I never thought my family would be the one. I think it is better to go to surgery, NOT thinking you will be the “statistic” as far as complications go. Anyone having surgery, SHOULD go into it feeling hopeful and thinking everything will go perfectly.
The article referenced below is a good review of this complication – stroke during coronary bypass surgery. The study is a retrospective review of 6682consecutive coronary bypass patients who only had the CABG procedure and not other simultaneousprocedures, such as carotid endarterectomy.
They list the possible sources of the emboli as the ascending aorta, carotid arteries, intracerebralarteries, or intracardiac cavities. They state that they believe the most likelysource is the ascending aorta, for the following reasons:
First, the ascending aorta is the site of surgical manipulationsduring CABG, whereas mechanical contact is not made with theother potential sources of emboli. Embolization of atheroscleroticdebris is most likely to occur during aortic cannulation/decannulation,cross-clamp application/removal, and construction of proximalanastomoses. However, embolization of atherosclerotic debrismay also occur when the aorta is not being surgically manipulated,due to the ‘sandblast’ effect of CPB.
Second, the majority of our independent predictors of stroke– elderly age, left ventricular dysfunction, previousstroke/TIA, diabetes, and peripheral vascular disease –are strongly associated with atherosclerosis of the ascendingaorta.
Third, our chart review suggested that the most common probablecause of stroke was atherosclerotic emboli from the ascendingaorta. Palpable lesions in the ascending aorta were noted ina large proportion of stroke patients.
The fourth reason we believe the ascending aorta is the likelysource of macroemboli is because of ancillary autopsy data.…….
Note the second reason given above – the independent predictors of stroke. My mother was over 74 yr so fell into the elderly age risk factor group. She was also a type 2 diabetic. She was noted to have a small abdominal aneurysm and some renal artery stenosis on the angiogram (an accidental pickup). So she had three of the four independent risk factors.
Aspirin? – Yes, I should take that to prevent heart attack and stroke, right??
Well……perhaps. A new study (called a meta-analysis), the largest comparative trial of its kind, shows that being overzealous about aspirin use for prevention of initial heart attack and stroke may be unsubstantiated.
Specifically 95,000 subjects were evaluated, producing 1671 vascular events in the aspirin group and 1883 in the control group. Aspirin was associated with an absolute reduction of 0.06% heart-related events per year. Correspondingly, aspirin did not significantly reduce ischemic stroke risk, but researchers noted a borderline-significant increase in hemorrhagic stroke. Aspirin also increased the incidence of bleeding outside the brain. Overall, aspirin was not associated with a significant reduction in vascular death.
What does it mean? The advantages of aspirin in low risk patients are scant. As cardiovascular risk factors (like smoking, high cholesterol, high blood pressure, diabetes, family history of early stroke/heart attack) pile up, aspirin gains a bit more support, though there is a modest associated bleeding risk.
We will be following this data and it’s analysis further. In the meantime, it may be reasonable to discuss things with your doctor, or perhaps cut aspirin dosing to the appropriate lowest dose (81mg in most patients).
Want the original?
See Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009 May 30; 373:1849. We will post the appropriate links after publication to make it easier.
*This blog post was originally published at eDocAmerica*
FROM THE “BEST OF EMERGIBLOG” FILES, ORIGINALLY POSTED AUGUST 16, 2005, THIS WAS ONE OF THE VERY FIRST POSTS OF THE THEN BRAND-NEW EXPERIMENT KNOWN AS “EMERGIBLOG”
I never knew this game existed until I did a web search for the character! There are actually pristine, unopened Cherry Ames games on eBay.
No, I didn’t buy one. Seventy-five dollars is a wee bit too much to pay, although I did spend that much on a vintage Barbie outfit about ten years ago.
Hey, it came with the original shoes and Barbie fans know it’s all about the shoes!
(UPDATE 5/09: My co-worker gave me all of her Cherry Ames books – a complete set – and a copy of the game, in perfect condition!)
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Those who study human behavior should spend a shift in the emergency department.
The games played in the ER make the Olympics look like a tetherball tournament. Some of the participants are patients and some are staff. Some are gold-medalists in their specialty and some arrive a few feet short of a full balance beam.
Let’s take a look at “The Emergency Olympic Games”:
“The Suck-Up”
Usually the player is suffering from an acute lack of an opiate prescription for chronic pain symptoms with a nebulous origin for which they have not been evaluated by a doctor but they have an appointment with a specialist next week but they ran out of their Vicodin and they just cannot bear it.
Said patient is overwhelmingly complimentary to Team Nursing . The targeted nurse is SO much nicer than any other nurse anywhere in the whole world and gee, that other nurse was so rude they wish ALL nurses were just like you! These compliments are dispensed within 3.5 seconds of spotting the nurse, often making said RN feel an acute need for a shower.
The player realizes she is out of medal contention when the targeted nurse responds with, “Gee, thanks, but I just came in to get a Betadine swab….”
”Mean Medical Matchup”
This game is closely related to the Suck-Up, utilizing the same team.
Player has been evaluated by the ER doctor, who, having the audacity to disbelieve their story, has gone for the gold and verbalized his lack of belief to the patient. Bottom line: no prescription. The patient prepares for this event with the “Which Doctor is On Tonight?” drill, using a telephone to assess the playing field before engaging the opponent.
“Peek-a-Boo Bypass”
This event requires a large team that converges on the patient’s playing field soon after the patient’s arrival. Anyone can make the Peek-a-Boo team, although it is usually composed of family members and friends of many generations.
Upon arrival, Team Nursing announces the event rule: only two members of the Peek-a-Boo team on the field at a time. This is met with a courteous response and extraneous members go to the bench in the waiting room, where the goal is getting back onto the playing field without Team Nursing noticing. This is accomplished by one Peek-a-Boo team member returning to the patient at a time until the bedside number has quadrupled. Stealth and dexterity are assets to this goal. Occasionally Team Security will act as referee.
“The Two Guy Offense”
The preliminaries for this event take place off the Emergency Stadium grounds.
The player reports a spontaneous assault by Team Two Guys. The members of this team are always unknown to the patient and the initiation of contact always unprovoked.
The goal of Team Patient is to obtain care from Team Medical with minimal disclosure of the playbook. The involvement of Team Police is always declined as so as not to incur a penalty. Team Two Guys apparently has many expansion franchises.
“The Two Beer Defense”
Team Patient enters the arena via Team Paramedic, having received a report of “player down” on the sidelines of a local Team Seven-Eleven. Team Patient arrives supine on a movable gamepiece.
Upon arrival in ER Stadium, body fluids are released for assessment by Team Nursing who immediately take defensive positions. Performance-enhancing ETOH is suspected as the characterisic Odor Offense is noted. Team Medical waits for the Designated Cleaners and takes the field.
Minimal interaction takes place between the teams for many hours at which point Team Patient verbalizes that he only had “two beers”. Team Medical knows to multiply this number by 58. Team Patient is taken out of the medals race on a credibility technicality.
“The Decibel Debate”
Team Patient attempts to propel themselves off the bench and onto the playing field by increasing their verbal intensity. Team Nursing counters with internal auditory blocking mechanisms. The goal: Team Patient enters playing field at appropriate interval. Team Patient rarely medals in this event.
“The Titanic Panic”
Team Patient arrives, usually via Team Paramedic, complaining of numbness, chest pain, shortness of breath and near-syncope occurring at the preliminary event at Home Arena which involved a “Decibel Debate” with another member of Team Family.
The Peek-a-Boo team arrives to act as cheerleaders for the event. No medal is awarded, as the full cardiac work-up that ensues turns out to be negative. An Academy Award nomination, however, would be appropriate.
These are just some of the Emergency Olympic events to which I have a front row seat and perpetual season tickets!
*This blog post was originally published at Emergiblog*
Heading out for a family walk over the weekend, we barely got beyond the end of the driveway before we quickly turned back…sunblock. We forgot to goop! A quick retreat back to the garage, we all lathered up and were on our way.
Over kill for such a mild sun day? Not in our experience. We’ve not only been caught off guard before and had “low intensity” sun days create rather intense burns behind necks, knees and arms, but have a family history of melanoma that haunts us ever time we step outside. My husband’s dad lost his life to melanoma. He was in the Navy and sunblock wasn’t what it is today, nor was the treatment for melanoma. He didn’t have the control we do today and would be really upset with us for tossing caution to the wind with our skin and our kids.
As reported by ABC news, there are 1 million cases of skin cancer a year and counting, melanoma, a year with 90% of those related to sun-exposure. We are truly playing with fire every time we step outside without sunblock on.
There’s nothing wrong with getting a tan if you some common sense and use sunblock – SPF 15 or higher with UVA and UVB protection. The key is to avoid becoming a french fry and to remember to reapply the sunblock liberally and often (each hour is the expert recommendation). As Dr. Doris Day, a NYC dermatologist interviewed by ABC noted: “You need to go through sunscreen…One bottle should not last a summer.”
Kids, too, need sun protection and it’s a myth that babies can not have sunblock applied to their skin. Infants older than 6 months of age can have the sunscreen applied to the entire skin and infants under 6 months of age can have sunscreen applied to very exposed area such as the hands and face in just the amount needed to cover those areas.
By the way, sun protection isn’t just for our weekend warrior moments. Think of it as part of your every day skin care. If your kids walk to and from school, they need sun protection. If you walk outside during your work day, you need sun protection. Many daily moisturizers now include SPF 15 and are great for that daily purpose where you need a bit of protection but not the intense protection as you do on weekends when outdoors more.
So, go ahead and get outside and get some sun…just do it safely and take the few extra minutes to apply sun protection. It’s fine to get a tan but no tan is worth dying for and that’s the point we all have to remember.
For more tips on sun safety for infants and kids, click here and here.
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