August 23rd, 2009 by scanman in Better Health Network, True Stories
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…in four parts, from Paul Levy’s blog.
It is, says Paul, “From a friend of a friend,” and it starts thus…
My son is sleeping right now…had a rough weekend – his blood pressure dropped, his blood count was decreasing, and he had chest and neck pain. The clinical team adjusted his meds, gave him a unit of blood, and are now trying to figure out what to do next. He is scared and worried and wants so desperately to be “normal” again. He is scheduled for leg surgery this afternoon and then we wait to see what the next steps will be.
While I have a few quiet moments, I thought I’d document the story of how he made it this far….it is a story of extraordinary luck and a fair amount of clinical heroism.
My son was born 17 years ago with transposition of the great arteries (his heart had over-rotated and was pumping in a way that didn’t allow oxygenated blood to move from the lungs to the body and back again) so he had a 9 hour operation at a week old to reconstruct his heart.
…read the rest of part one
…and parts two, three & four.
Here, in my opinion, is the best passage from the entire saga…
My son is receiving absolute top-notch care from the only place in the area that could have saved him, but was by luck, not by any “consumerism” on our part – we didn’t Google “teenage arterial switch survivor with heart attack” or pull up HealthGrades to find the best hospital or doctors to treat him….we have benefited from the kindness and skill of a community of health care providers affiliated with a hospital that was uniquely situated to help him, but the only choice we had in this was what hospital to drive him to.
…
In part 2, we learn the reason for the young man’s sudden collapse…
We learned much later that the problem that caused the heart attack was due to his reconstructive surgery when he was a baby…as he grew and became more active, one of the reimplanted coronary arteries became pinched between the rebuilt pulmonary artery and the aorta….this was an inevitable result of the surgery that saved his life 17 years ago and would have happened at some point – while swimming, riding his bike, walking in the neighborhood, playing lacrosse, or running by himself in the neighborhood as he trained for cross country….so the fourth link – he happened to have his attack while at a school with trainers equipped with an AED, with coaches and parents and teammates right there ready and able to help him. He wasn’t alone….and he was in the best possible place to have his attack (even though he complicated things a bit by having it in the woods and falling down a steep bank)
…
Congenital cardiovascular abnormalities, especially anomalous coronary arteries, are amongst the commonest of causes of sudden cardiac death in athletes.1 Ramona had posted about a young man who collapsed and died during the Little Rock Marathon in 2008. That unfortunate young athlete had a rare disease of the coronary arteries.
Coronary artery anomalies constitute 1–3% of all congenital malformations of the heart. In approximately 0.46–1% of the normal population, anomalies of the coronary arteries are found incidentally during catheter angiography or autopsy. The etiology of coronary artery anomalies is still uncertain. Maternal transmission of some types has been suggested, particularly when only a single coronary artery is involved. Familial clustering is also reported for one of the most common anomalies, in which the left circumflex coronary artery (CX) originates from the right sinus of Valsalva. Anomalies of the coronary arteries may also be associated with Klinefelter’s syndrome and trisomy 18 (i.e., Edwards syndrome). Cardiac causes for early and sudden infant death include anomalies of the coronary arteries; the Bland-White-Garland-Syndrome may be one relevant cause. Anomalies of the coronary arteries found in children may be associated with other congenital anomalies of the heart like Fallot’s syndrome, transposition of the great arteries, Taussig-Bing heart (double-outlet right ventricle), or common arterial trunk.2
Normal Coronary Arterial Anatomy
Common variants are anomalies with origin from the contralateral side of the aortic bulb. These include an origin of the LMA or the LAD from the RSV or the proximal RCA and an origin of the RCA from the LSV or the LMA. There are four possible pathways for these aberrant vessels to cross over to their regular peripheral locations: (1) “anterior course” ventral to the pulmonary trunk or the right ventricular outflow tract, (2) “interarterial course” between the pulmonary artery and aorta, (3) “septal course” through the interventricular septum, and (4)”retro-aortic course”. Clinically, course anomalies of the coronary arteries are subdivided into “malignant” and “non-malignant” forms. Malignant forms are associated with an increased risk of myocardial ischemia or sudden death and mostly show a course between the pulmonary artery and aorta (i.e., “interarterial”). The most common case is an origin of the RCA from the LSV that courses between the aortic bulb and the pulmonary artery. Anomalies of the LMA or the LAD arising from the RSV with a similar course are associated with higher cardiac risk, too. It is suggested that myocardial ischemia and sudden death result from transient occlusion of the aberrant coronary artery, due to an increase of blood flow through the aorta and pulmonary artery during exercise or stress. The reason is either a kink at the sharp leftward or rightward bend at the vessel’s ostium or a pinch-cock mechanism between the aorta and pulmonary artery. Up to 30% of such patients are at risk for sudden death.2
…
The young man in this story probably had something like this after the surgical correction (Arterial Switch Operation) for TGA…
“Malignant” course of LAD
…a classical malignant course of the LAD between the Aorta and Pulmonary artery.
…
References:
- Sudden Death in Young Athletes: Screening for the Needle in a Haystack – Free full text article in American Family Physician.
- Text about congenital coronary artery anomalies and the two figures are from this textbook – Multi-slice and Dual-source CT in Cardiac Imaging.
Start Slide Show with PicLens Lite 
*This blog post was originally published at scan man's notes*
August 21st, 2009 by CodeBlog in Better Health Network, True Stories
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Just over a month ago, our unit had several H1N1 flu patients. And they were sick. Really really sick. They were also fairly young – 30’s to 50’s. I wondered at the time why the media hullabaloo about the flu had died down when I was seeing more and more patients in my unit who had it.
Last time I worked there was only 1 flu patient and they weren’t too sick (yet?) to require a ventilator. I was really glad to see the decrease in this particular patient population. I won’t lie – it’s frightening to be a nurse caring for someone with a highly communicable disease. Masks, gloves, gowns are all provided by the hospital, but I can’t ever shake the feeling that I’ve somehow come in contact with it despite these precautions.
And what of the times that we admit patients and don’t know they have a communicable disease? At least one coworker I know of contracted H1N1 from taking care of a patient who had it before we knew they had it.
I’m sure she was quite shook up – every single patient who turned up positive for the flu in our unit in that time period ended up literally fighting for their lives on a ventilator.
The most harrowing patient we had was a woman in her 30’s who was pregnant. Like the other patients, every time she coughed on the vent, her oxygen saturations would decrease to the 80’s and would take a long time to come back up. Unlike the others, though, she was so fragile that sometimes merely coughing on the vent caused her to go into asystole.
I’m somewhat jaded about coding people at this stage in my career. I remember, as a brand new ICU nurse, talking to a well-seasoned ICU nurse. She said that hearing “code blue” being announced overhead didn’t give her any kind of adrenalin rush anymore. At that time, I couldn’t imagine being in that frame of mind. Being new, I was expected to go to every code blue that was called so as to get experience. My heart started going into SVT at simply hearing the word “code.” If the word “blue” came after I practically had to defib myself before running off to defibrillate the patient.
I eventually got to a place where I could fairly confidently go run a code without freaking out. I’ve been an ICU RN for 11 years. In those 11 years, there have been some awful codes. Two stand out in my mind, and the absolute worst was on the pediatric floor. When I heard “code blue, pediatrics” overhead, my first (naive) thought was, “little kids code???” My second thought was to wonder if it was really an adult overflow patient. Sometimes the gyn surgeries went to the pediatric floor if there was no more room on the surgical floors. You know, maybe one of them got a little too much morphine and the nurse called a code. A little Narcan, a few bagged breaths and everyone would sigh with relief and go on with their day.
No such luck. After running full speed up 3 flights of stairs, I arrived at the room that had the most people spilling out of it only to find a bald, thin 5 year old in the bed. I thought I was going to be sick. PICU nurses – bless you all. I could not do that for any length of time.
She didn’t make it. Having been a nurse for a couple of years at that point, my naivety about the world already had a few chips and cracks in it. But on that day a huge chunk fell out.
Since then I’ve come to be more like that seasoned ICU nurse that I spoke with so early in my career. Along with the semi-jaded “oh crap, a code blue” comes a confidence in one’s abilities, so it’s not all bad.
However, watching that woman go into asystole, knowing that we would have to crash c-section her if she stayed in it? That took me back to the days when I was new and inexperienced. I’ve never seen anything like that happen. Although I was perfectly comfortable with my (pre-arranged) personal role, the overall situation would be completely new to me.
Although HIPAA prevents me from saying much more, I will say that I did not have to experience that situation; not because I was off when it happened but simply because it never happened.
If it had, it surely would have made my top 3.
*This blog post was originally published at code blog - tales of a nurse*
August 19th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Health Tips
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If you are a family with kids and have grandparents or great grandparents alive, you likely enjoy visiting with your relatives from time to time. While your small children may not always get much out of these visits, especially while very young, they do wonders for our older relatives who so enjoy visits from family and delight in seeing us become parents and expand our families.
I remember vividly visiting my grandparents as they aged, as a child, a teen, a young adult and when I became a parent with my own infants and toddlers. I recall well their delight…and the vivid images of their aging lives: durable medical equipment like canes and walkers in the corner of the room. And, the kitchen counter with rows of medication bottles that made the counter appear like the pharmacist’s counter at the local pharmacy. Given all of my grandparents had arthritis towards the end of their lives, none of those bottles had child-resistant tops.
Whether at home, an assisted care facility or a nursing home, the issue I worry about with small kids are floors and medications. Even if someone is handing an older person their medication, a pill can fall to the floor without being noticed and later found by a toddling child who mistakes it for a piece of candy. That’s what happened last week when 15 month old boy found a shiny pink pill on the floor of his grandmother’s house and didn’t think twice about tossing it in his mouth. Thankfully, it was bitter so he spit most of it out but it was a blood pressure medication so we had to given him activated charcoal, a lot of it, and then observe him in the emergency room for 6 hours.
This story had a happy ending but could have been a disaster had it been a different type of pill or a higher dose, or a group of pills. It’s very, very important that we all take a moment to think about the pill safety of our older relatives – for their sake and the sake of the small children in their lives. In addition to products that can help dispense pills more safely, making sure floors are clean before visits and supervising kids during visits are essential.
As an aside, the moral to this story can be extended to hotels and homes we may visit that we are not as familiar with. Pills can easily fall out of pockets, purses and luggage. When traveling anywhere with small kids, get on the ground and look under beds, chairs, sofas, pillows and be sure there are not any pills or other small items that we wouldn’t want our small children, or even older children, to touch, or worse – eat!
BTW, can you find the pill in this picture? Hint: it’s blue.
See On The Edge Of Something blog for the “before” shots showing the pill in a spoon on the floor.
Not so easy, huh? Unless, of course, you are a very small child with the eye sight of a falcon and live close to the ground routinely. Now do you get the point?
*This blog post was originally published at Dr. Gwenn Is In*
August 19th, 2009 by Nancy Brown, Ph.D. in Better Health Network, Opinion
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Teens living with a depressed parent need information and support. The inclination of most people living with someone who is depressed is to take on responsibility for the ill parent and other family members.
Life is difficult for anyone living with a depressed parent. The daily home life is complex – with little consistency, irregular habits, plans made at the last minute, little consideration for each person’s wishes or desires, and there is usually a huge decrease in communication. The depressed parent withdraws from the family and the teens are left to manage on their own, creating feelings of loneliness.
Teens are not likely to realize how much their life has changed, or how serious the depression is and need adults who see the changes to bring them to the attention of the family, medical and emotional professionals. Even if the depression lifts for a period, everyone in the family will likely be anxious about when it will returns.
I believe that all health care professionals are ethically responsible to help teens avoid the responsibility and loneliness associated with living with a depressed parent. As mentioned in a previous post, there are also many resources for those parents who are willing to admit the depression, as well.
This post, Teens Who Live With A Depressed Parent, was originally published on
Healthine.com by Nancy Brown, Ph.D..
August 12th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network
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During a recent emergency room shift, I treated a 12 year old boy for a swimmer’s ear. During the visit, I learned he was from the South and was in the area visiting relatives before starting school in a couple weeks. It turns out he’s been battling this pain for a couple weeks and his mom is convinced it’s because of all the swimming he’s done this summer. Instead of rushing him to his own pediatrician at home, she has been “riding it out” to see if the pain resolved on it’s own.
This was true music to my ears! Most parents rush their kids to the doctor at the first sign of ear pain, even though the current recommendations are to not use antibiotics in this age group unless the pain persists or worsens past the first few days. So, if his exam were abnormal, my decision making process would be much simpler.
What wasn’t music to my ears was learning I was the second physician to see the boy that week. The grandmother took him to see her physician when she had a scheduled appointment a couple days earlier, “just for a curbside” and learned that he did in fact have “an ear infection”. No medications were given or appointment facilitated with a pediatrician or other physician. This was truly just a curbside. The family was left with no alternative but to use the ER.
The ER often ends up being our only option when visiting an area out of town, isn’t it? If staying at a hotel, many do have a cool option that provides a physician call service so a physician will come to you, as I learned a couple year’s back in Disneyland. And, some cities do have free-standing urgent-care centers that can help with these sorts of non-911 situations. But, by and large, the ER is it in most areas and for most people.
What a backwards situation! The majority of sick people have situations that do not need the ER yet find themselves having to because there are simply no other options. Think about how much time and money would have been spared for this family and the system had that first physician just seen the child as an office visit and written the same prescriptions I wrote 2 days later during the ER visit. Think about the healthcare savings to the system and personal savings to families if we had the same theoretical options to the hundreds of thousands of annual after-hours urgent care visits our system sees each year but is current seeing in the wrong setting!
In the big picture, seeing a basic sick visit after hours in the ER is like trying to crack a nut with a sledgehammer. It makes about as much sense, too. The truth is we just have no place for the after hours regular sick people, which, by the way, are the majority of people who get sick after hours, especially if their doctor is in another state!
It’s really not a shock ER wait times are so long…ERs are over loaded with patient’s just like this boy. Until we find a better system, better take along your iPod and a good book should you find yourself heading to the ER. You’ll be in very good company waiting to be seen so may as well come prepared for the wait.
*This blog post was originally published at Dr. Gwenn Is In*
