6.10.2013

A TRUE LESSON

Today's Basic Clinical Skill (BCS) session has to be recorded somewhere... eternally. But nothing is eternal, except the life in the hereafter. So I'll just... write it down here, I guess.

The skill that we were trained for was examining respiratory function of a patient. It was our second session, so we were supposed to revise the materials which have been taught on the earlier session and be graded for it. BCS sessions in my uni are stereotyped to being hardly punctual, because the tutors (who happen to be doctors) almost always come late (or never come at all after two hours of waiting in vain and so it often ends to reschedule). With that experience, I somehow tend to make a late appearance, including on today's session.


*me rushing to the BCS class carrying my lab coat on one hand and a plastic bowl of Instant Ind*mie on the other, I was two minutes late because I forgot that I had a BCS session that day and so I didn't bring my lab coat (which was required for us to wear throughout the session) so I had to buy one (yes, I bought one) (what? I don't really own a decent lab coat, most of 'em have undergone a gradual shift of color*


I was really surprised to see that the tutor for that evening actually came on time. Frankly, I was hoping he'd be checking in late because I haven't reviewed the topics. Oh God, I felt that I was doomed.


I knocked and he let me in peacefully. There were supposed to be seven students in the class but it appeared that I wasn't the last one to be late. Minutes later, the rest had walked in and taken their seats. And the doctor (who had never stopped interacting during the whole waiting, mostly was asking about who, in our class, was from Malaysia) finally addressed to us all in a moderate tone but sounding not any less convincing,


"You know, you students are about to become doctors. You aren't supposed to be late. Ever. Just imagine if one day, your patient is already dealing with chest pain, dizziness, nausea, and all other grueling symptoms and has to endure long for you to be present, and yet you come to face him knowing that you're already late, in a very relaxed manner. That is very unethical."


He spoke not in a strict demeanor, but more like a person who strongly believes in his principles, and strongly believes that they are beneficent. Truthfully, I fell into immediate respect towards this tutor, who stood up for something which had to be corrected in us. Unlike other tutors who, let alone letting those acts go by, barely attend the session befittingly. I was pretty sure we were all aware of the emphasis of being on time. In fact, I was sure that most of the time we do know the good qualities that shape us into a better individual, but nevertheless, most of us tend to think that we'd be given another moment in life to shape ourselves better.



***

"Let's begin. This is your second session, correct? So, prior to this, you have been introduced to performing physical examination of the respiratory tract, then. Who was your tutor?"


Silence. *seven foreheads frowning, hopelessly trying to recall the name of the tutor*


"How can you not know your tutor's name? Do you recognize me or not?", he asked, his beholding eyes towards me. His latter question wasn't indicating that he wished to be acknowledged, even though I did sense that he wasn't just any doctor, or any person. It was purely an appropriate question.


"Um..", I hesitated. He did look familiar. I think. But I took too long to think. And I didn't know why others fell into deep silence as well.


"Okay. I want one of you to step out right now, and find out about my name," he decided, "Now."


I wasn't the one sitting closest to the door, but my reflex was bizarrely the fastest. I somehow felt ashamed of not knowing the name of the person who was assigned to provide me knowledge of skills that I needed to master, to save at least a single soul of a patient in my later professional years.


I headed briskly to the BCS administration office, which was located right next to my class so it was a brief journey, searched through the files like a mad investigator, then I found the suspect's name: Prof. dr. M****** R****. But that wasn't just it, I had to look up our previous tutor's name as well, out of curiosity.



***

"After examining the trachea of the patient, how do you report your findings?", asked Prof. M.


A friend of mine, gave attempt in answering, "We.. state that it's normal and –"


"Normal? What defines normality?", he interrupted.


"You can't say it is normal. Because all of us are created in variety, including our trachea. None of us is normal. But that doesn't mean we're abnormal; we just vary. So, what you have to do is just simply elucidate what you see, what you feel, trust your senses."


There is no tracheal deviation.

***

"Don't hesitate to give your answer. Don't be scared of being false. This is the only period where you can make mistakes. Once you've become a doctor, one mistake you do is responsible for risking the continuity of a person's life. Share, discuss, and remind each other of what is right."


***

"Learning is habit. So make a habit out of what you learn."


***

"Treat your patient exactly like how you want your doctors to treat you."

***

I trust that every incidence, no matter the magnitude (big or small), that happen in our daily life, contribute in changing, developing a part of ourselves into becoming who we are today.

6.07.2013

CARDIAC EMERGENCY

A BORING INTRO – if you’re reading this a day before the summative, skip it.
What you should be aware of is that, Cerebrovascular disease is held responsible for causing the death of major people worldwide and patients suffering from it couldn’t carry on living their lives normally because the symptoms are a drag and it disturbs their daily activities. Responding to that, health workers, researchers and medical students (YES! YOU!) study their ass off on determining preventive steps on at least having less people to die from this disease, and instead die peacefully without any painful symptoms. They begin with listing down the factors that may cause people to have higher chance of getting CVD, and when it turned out that some of these factors cannot be played with (such as age, family history, race, and sex), they just persuade people to quit smoking, control blood pressure, cholesterol and blood glucose levels, go on a safe diet, exercise more, and give up from studying medicine (in other means, avoid stress), all of which are considered as modifiable risk factors.

CARDIAC EMERGENCY – how can we tell its an emergency?

When can we really tell that we’re facing a cardiac emergency? According to AHA, whenever the heart is deprived of oxygen (ischemic), because the consequence is the inability of the heart to function, and that main function is to feed all parts of your body with oxygen (which is so friggin important!!) and the ultimate result is eventually organ dysfunction but the most fatal condition is when the brain couldn’t attain oxygen. So, in that case, when can we tell that a person’s heart is deprived of oxygen? The actually really truly most common obvious symptom is diaphoresis (basically means excessive sweating), which occur in 78% of patients who have their heart screaming, “Dude I need oxygen, like, right now”. The symptom that deserves the second rank for suspecting oxygen-deprived heart is chest pain (which arise in 64% of these patients). Complaints of chest pain are considered a serious indication for cardiac emergency, and for this reason, complaints of chest pain are always considered to be an AMI (Acute Myocardial Infarction, or we can say early signs of heart attack) – until proven otherwise (meaning that it may be a respiratory or other systemic problem). Other classical symptoms are nausea, pressure and heaviness on the chest, and weakness.


Difference between Myocardial Ischemia & Myocardial Infarction
I was personally very confused regarding the difference between those two and so I looked it up in a number of references, so if anyone is still as confused as I was, here I put down the explanation. Yes, you’re welcome. So, starting from the word “myocardial”, it refers to part of the heart that contains muscle tissue. While “ischemia” means deficient supply of blood to a body part (as the heart or brain) that is due to obstruction of the inflow of arterial blood (MerriamWebster), and “infarction” signifies as an area of necrosis in a tissue or organ resulting from obstruction of the local circulation by a thrombus or embolus (MerriamWebster too). We can say that this guys has a myocardial infarction if theres a part of his heart that is already dead, but in myocardial ischemia, death of a part of the heart has not yet occurred. Myocardial ischemia is an event that will sooner or later lead to myocardial infarction. So, when myocardial infarction occurs, myocardial ischemia has certainly come about, but if there’s myocardial ischemia, myocardial infarction may not be necessarily to have taken place (but it eventually will).



ANGINA PECTORIS – why does chest pain occur so frequently in myocardial ischemia?
Chest pain, or we can use the cool word, angina pectoris (Angina, in latin is “angere”, means "to choke or suffocate". And pectoris, also in latin “pectus”, means chest. Long time ago, people who suffer cardiac chest pain describe the pain as being strangled by someone, hence the term. Angina pectoris is also a name of a band, look it up!), usually occur in myocardial ischemia. Let’s just jump to the explanation of why it happens. So we do know that the muscle tissue in the heart undergoes metabolism to generate energy/ATP, and it requires oxygen to accomplish it (a metabolic process we’re already familiar with, named aerobic metabolism). But the thing is, in myocardial ischemia, the heart fails to fulfill the oxygen demand, which is needed by the tissue to undergo aerobic metabolism. Despite the inadequate blood flow that leads to the insufficient amount of oxygen, the heart muscle tissue cannot hang on false hope by waiting for enough oxygen to come by, it has to metabolize anyhow, and so it goes under a metabolic process called anaerobic metabolism, and at the mention of anaerobic metabolism, the thing that has to immediately come into your mind is “oh damn but the product of anaerobic metabolism is lactic acid and CO2!”. Due to the accumulation of those nasty bastards (lactic acid & CO2) in the muscle tissue of the heart, pain results.
When people exercise, automatically the heart must pump harder (which is conducted by the muscle tissue of the heart) because the rest of the body demands higher amount of oxygen to generate more movements. In that case, the current of blood flow must run more rapidly. But if the blood vessel is partially blocked (like in the case of atherosclerosis), blood flow is somehow slowed down and the consequence of this is that it cannot fulfill enough oxygen (ischemia) that is needed by the heart muscle in high amount to pump enough blood to the rest of the body, and since theres just not enough oxygen, the heart muscle tissue again undergoes anaerobic metabolism and so, pain results there on the chest, where under it lies the heart muscle tissue that is ischemic. This is an example of stable angina, where chest pain constantly occurs when one does an exercise/vigorous activity or after eating a heavy meal, but stops when one rests. This condition still has a better prognosis compared to unstable angina, where chest pain takes place randomly regardless of what the person is doing, and wouldn’t go away even if the person rests or takes meds. Imagine how frustrating that is. Oh, and, remember, there are three Es that contribute to chest pain: exercise, eating, and emotion (stress).

Emergency Steps – including steps for cardiac emergency
Whatever emergency situation you’re facing, there are certain constructive steps emergency workers follow routinely before jumping to treatment.
  1.  BSI (Body Substance Isolation – lindungi diri) & scene safety. Make sure to wear protective tools such as hand gloves, masker, etc, and remember to see if the victim/patient is in a safe area, where you also can conduct your treatment safely without any dangerous interruptions. See if the victim needs to be transported to a safer area or not.
  2.  Initial Assessment. This step is like, your very first (initial) impression upon seeing the victim/patient. See if he/she receives enough oxygen or if the airway is blocked or not. Basically, we check the ABC (Airway, Breathing and Circulation).
  3.  Focused Exam. This step is carried out with regards of two aspects: subjective and objective. Subjective data means that it can turn out not to be exactly correct, such as the patient’s age, sex (yes! You have to ask!), and chief complaint. We obtain those data by means of asking. Investigate the situation by reviewing SAMPLE (Signs & Symptoms, Allergy, Medication, Last meal, and Events that lead to the occurrence of accident/happened before the incident). For the Signs & Symptoms (for symptom of CHEST PAIN, remember to explore more by asking OPQRST (Onset (when did it start to occur), Provocation (does it come after doing an exercise/eating or during work? This is to identify whether it is stable/unstable angina), Quality (ask the patient regarding the pain with specific description such as ‘sharp’ or ‘blunt’ pain), Radiation/Regional (only on the chest area or radiating to the arm/jaw, also see if the victim can/cannot pinpoint exactly where the pain is), Severity (request the patient to evaluate the scale of pain from 1-19) and Time (how long it has been going)). Objective information are findings that are evidently true, such as the level of consciousness (evaluate it when you listen to their response as when you obtain the subjective findings), the color of their skin and its’ temperature, the pulse rate, the blood pressure (but at a positive complaint of chest pain, check both arms), the papillary reaction and their breathing pattern. Also, in this step, if you find any abnormalities of the objective findings, you have to dig in to it deeper. For example, if the person is breathing with so much effort, then you need to listen to their breath sound and administer oxygen. Or if there’s chest/abdominal pain, then you have to palpate it. At the findings of CHEST PAIN, recall that you’ll most probably find diaphoresis, shortness of breath (dyspnea), nausea and weakness.
  4. Detailed Exam. The conduction of this step is thoroughly done from head to toe. Check for DOTS (Deformity, Open wound, Tenderness, and Swelling) and for any findings of abnormality, do intervention (such as cleaning the wounds, and applying compression on the swollen areas).
  5. Assessment. The most probable diagnosis that you can think of after accomplishing the subjective and objective findings. This determines your plan of action and treatment for the victim. If you misdiagnose, then the treatment will produce no effect or even a worse effect. God, its so hard being a doctor…
  6. Plan. Do the treatment! But before that, make sure that the Airway, Breathing and Circulation are stable beforehand, those three must be constantly monitored. Besides the ABC, other vital statuses, such as temperature, must be maintained. After that, see if the patient is in a comfort position or not! If not, intervene or transport him/her to a more comfortable spot if necessary. If the victim/patient is suffering from chest pain, give medications to relieve the pain. According to American Heart Association (AHA), if a patient comes with chest pain, there’s this specific algorithm of medication you need to give to ease the pain, abbreviated as MONA or ANOM. Let’s use ANOM because we’re more familiar with that name ;) A stands for Aspirin (as an anti-platelete, to prevent platelete aggregation), N is for Nitroglycerin, O is Oxygen (remember that they commonly come with shortness of breath/dyspnea), and M is for Morphine (to alleviate excruciating pain).
There are various forms of emergency situations that take form due to condition of ischemic heart. Down here, we discuss some of those that are common to occur as a complication of myocardial ischemia.

Complications of Myocardial Ischemia – Cardiogenic Shock, Aortic Dissection, Aortic Aneurysm and Cardiac Tamponade
Cardiogenic Shock
Shock is a term to describe inadequate blood flow supplying the organs of the body. In cardiogenic shock, the hypoperfusion is caused by the heart not being able to pump enough blood (the cardiac output and stroke volume are low, and since cardiac output volume affects the blood pressure, then systemic blood pressure will drop). If it’s because myocardial infarction, then its due to the death of the myocardium (especially of the left ventricle) which result in decreased contractility (weak à not strong enough to pump blood to the rest of the body). The symptoms are obvious: anxious and restless (altered level of consciousness due to brain hypoxia), pallor (because of insufficient blood flow), tachycardia (since the heart couldn’t pump strong enough, it tries to compensate by beating faster), hypotension (due to dropped cardiac output).

Thoracic (Aortic) Dissection
Recall in the vessel of the aorta, the blood is pumped to travel to the rest of the body. But if there’s a tear/scratch like in the second vessel tunnel in the picture, the blood that is pumped upward goes to two directions: the normal direction and the space created by the destroyed wall of the vessel (and the blood remains there). This is what happens in aortic thoracic dissection: a separation of the aorta wall. If the blood that gets stuck in the dissected area of the vessel, it can grow larger and eventually block the normal vessel. OHO! And so the aortic vessel is blocked and the consequence is the inability to deliver blood to the body and… well the patient dies in due course. And that’s why its also an emergency condition. This condition feels very painful. Patients that have this usually complain of severe chest pain or sharp/ripping sensation in the aortic area (typically at the center of the chest).

Aortic Aneurysm
The aorta, as the largest artery and a bridge that picks up the blood from the heart to the rest of the body, is the most common artery to develop aneurysm. What exactly is an aneurysm? The blood vessel in the human body normally has a thick wall to maintain the pressure of the blood flow. But if a part of the wall is weakened, the pressure of the blood flow pushes it outwards and creates a bulge/balloon, and this is known as aneurysm.


Cardiac Tamponade
This abnormality actually has a cute term. Tamponade, comes from the word ‘tampon’ (or softex/pembalut). I honestly don’t know the relation but… Cardiac tamponade is when the space between the myocardium and pericardium is accumulated with fluid (the fluid can be blood). In a normal situation, there is fluid, but in a limited amount, only to allow the heart to move freely without generating friction. But if there’s too much fluid in there, the heart is compressed, like shown in the picture (the thick red space shows accumulation of the fluid). So the thicker the accumulation of the fluid, the less space the heart has to move and pump because its’ too narrow, and because of that, the heart has limited ability to function. So, I guess, you can relate cardiac tamponade with tampon by imagining someone put a tampon in the pericardial space. Cardiac tamponade is an emergency condition. So how do we know if we’re facing a patient with cardiac tamponade? The three principal features of tamponade (known as Beck’s triad) are hypotension, soft or absent heart sounds, and jugular venous distention with a prominent x descent but an absent y descent (I don’t…really understand the last feature).