I spoke to a patient yesterday and was just blown away by some of the history we have in our facility. My PT told me how Z. had been a POW in Germany and then queried me as to how I thought Z.'s legs got messed up. I had no idea, but then was informed that the Nazis flooded the mining camp and broke Z.'s leg. It was never fixed, because Nazis have no hearts. Z. was set to be hanged on Easter Sunday, but was able to escape and made way for Canada.
It's incredible that I can be privy to this kind of thing. Z.'s really an easygoing person, which is amazing after going through so much. Z. answers everything with, "Yes, thank you very much!", and only complains of shoulder pain every so often, but otherwise is just an incredible individual.
It's nice to know that even after pain and suffering there is solace in a positive attitude and an embracing of life.
Showing posts with label clinic. Show all posts
Showing posts with label clinic. Show all posts
5.05.2010
12.10.2009
day last
Sorry I've been so busy. I've been posting on the PT discussion board rather than on here. I'll have something up real soon.
12.07.2009
day one
palpate ventriculoperitoneal shunt. inhibit student reflexes. score BERG in <8 min. ambulate patients alone. observe student doctors cower in fear from their supervising physicians in rounds. paraphasia. patient describes leg as a 'peg' due to impaired sensation and proprioception. donepezil. BAKING COOKIES TOMORROW WITH OT. presence of neuropsychologist and recreation therapist. resident failing miserably at social skills with patient and staff. how different OT and PT goals are. GOING SWIMMING WITH PATIENT TOMORROW. neuroplasticity - temperature sensations to the hand would also be felt in his lips (think: homunculus). how PTs are known to be hardasses. Takayasu's Arteritis. how Dutch people love to talk, even with aphasia.
HOW AWESOME PLACEMENT IS.
HOW AWESOME PLACEMENT IS.
9.27.2009
PED
The vascular intervention world has been buzzing with exciting news as of late. EV3 recently purchased Chestnut Medical Technologies and is now beginning to offer their products to the cerebral angiography community.
One of the most exciting new products that's out there is the Pipeline Embolization Device (PED) which was developed by Chestnut. The PED is a v. flexible, microcatheter-delivered, self-expanding endovascular "stent-like" construct used for the occlusion of cerebral aneurysms. It is created from microfilaments of platinum and cobalt chromium which are braided to form a mesh cylinder. The device is delivered so that it expands to oppose the walls of the parent vessel from which the aneurysm arises, and acts to completely occlude the aneurysm from receiving circulation while simultaneously encouraging reconstruction and normalization of cerebral vasculature in the affected area.
One of the papers I read delivered a fantastic history detailing the history of aneurysm treatment. In 1992, Boston Scientific/Target created the Guglielmi detachable coil system which opened up the world to treatment of aneurysms with metal coils. 10 years later, Boston Scientific introduced the Neuroform stent, specifically used as an adjunct to coil embolization. That being said, the best evidence practice for the last couple of years has been to coil and stent.
The problem with this method is that it fails dramatically for aneurysms that are not narrow-necked, berry-shaped and small. Not everyone is blessed enough to have only a tiny aneurysm, and there's many a time in clinic where I've been witness to gigantic aneurysms - you really wonder how these people live. When you look at the statistics, 38.3% find complete occlusion at the 12 month follow-up. Another study found a 19% rate of complete occlusion at 18 months. While the rates are much better for small aneurysms (66%), there are still a rather large percentage of those not receiving a clean bill of health. These include those with small aneurysms, and most dramatically, those with large, giant, wide-necked and non-saccular (fusiform) aneurysms.
So let's examine why. When examining the coiling, we note that with maximal packing, the majority of the volume within coiled aneurysms does NOT get filled with embolic material (70-80%). This allows for blood flow to continue into the aneurysm. It is also dangerous to breach the sac of the aneurysm in the first place, so avoidance of aneurysm entry would be optimal. When considering adjunctive stent placement, many stents provide inadequate metal area coverage when deployed. The Neuroform stent itself provides only 6.5-9.5% metal coverage, and so cannot act as a stand-alone therapy.
In comes Chestnut/EV3 with the PED. The PED provides 30-35% metal coverage at maximal expansion, which is obviously much higher coverage. It is deployed just proximal to the neck of the aneurysm in the parent vessel, and thus does not require entry to the aneurysm sac, effectively circumventing accidental perforation. The deployment provides sufficient coverage to physiologically exclude the lesion from circulation, yet is porous enough to preserve the patency of branch vessels covered by the construct. The really cool thing about it is that not only does it effectively occlude aneurysm blood flow (>90% reach full occlusion by the 6-month followup), it facilitates the growth of normal vasculature in the region - "the stent implantation may change the configuration of the parent vessel, changing the anatomy of the parent vessel-aneurysm complex and the aneurysm inflow zone...implantation of the stent within the affected vessel ideally acts as a stimulus and provides a scaffolding to support neointimal overgrowth across the aneurysm neck defect, thereby facilitating the biological remodeling of the deficient segment of the parent artery".
One of the most incredible things is that the PED can act as a stand-alone therapy (15/17 aneurysms in rabbits achieved complete occlusion with only one PED deployed). This may represent a paradigm shift from coiling to stand-alone stenting in the future. From an economical perspective, it will be much cheaper to perform this, both on the basis of materials required (one-three stents vs. ten coils +/- adjunctive stents) and on radiologist time spent in procedure.
With all new products, there are obviously limitations. Placement of the PED precludes future coiling because it blocks neck access, therefore the suggestion has been to jail a microcatheter in the event that re-entry is required. There is also no clear evidence to show how PED affect bifurcation aneurysms, and if occlusion of one side will increase flow to the next one. Lastly, there is dual antiplatelet therapy required during the procedure (aspirin and clopidogrel), which is obviously contraindicated for the context of acute subarachnoid hemorrhage.
Nonetheless, the PED invites a new way to look at cerebral vasculature intervention, and shows that even today companies are still paving the way towards new technologies to aid those afflicted by disease. I think the most exciting thing is that this is no band-aid solution - the PED acts not only to cut off blood flow to the aneurysm, but it also encourages the growth of appropriate vasculature through its scaffolding. HOW FREAKING COOL.
You can read the original papers by clicking on the titles of the papers below:
***
Lylyk, P., Miranda, C., Ceratto, R., Ferrario, A., Scrivano, E., Luna, H. R., et al. (2009) Curative Endovascular Reconstruction of Cerebral Aneurysms with the Pipeline Embolization Device: The Buenos Aires Experience. Neurosurgery, 64(4), 632-643.
Fiorella, D., Woo, H. H., Albuquerque, F. C., & Nelson, P. K. (2008). Definitive Reconstruction of Circumferential, Fusiform Intracranial Aneurysms with the Pipeline Embolization Device. Neurosurgery, 62(5), 1115-1121.
One of the most exciting new products that's out there is the Pipeline Embolization Device (PED) which was developed by Chestnut. The PED is a v. flexible, microcatheter-delivered, self-expanding endovascular "stent-like" construct used for the occlusion of cerebral aneurysms. It is created from microfilaments of platinum and cobalt chromium which are braided to form a mesh cylinder. The device is delivered so that it expands to oppose the walls of the parent vessel from which the aneurysm arises, and acts to completely occlude the aneurysm from receiving circulation while simultaneously encouraging reconstruction and normalization of cerebral vasculature in the affected area.
One of the papers I read delivered a fantastic history detailing the history of aneurysm treatment. In 1992, Boston Scientific/Target created the Guglielmi detachable coil system which opened up the world to treatment of aneurysms with metal coils. 10 years later, Boston Scientific introduced the Neuroform stent, specifically used as an adjunct to coil embolization. That being said, the best evidence practice for the last couple of years has been to coil and stent.
The problem with this method is that it fails dramatically for aneurysms that are not narrow-necked, berry-shaped and small. Not everyone is blessed enough to have only a tiny aneurysm, and there's many a time in clinic where I've been witness to gigantic aneurysms - you really wonder how these people live. When you look at the statistics, 38.3% find complete occlusion at the 12 month follow-up. Another study found a 19% rate of complete occlusion at 18 months. While the rates are much better for small aneurysms (66%), there are still a rather large percentage of those not receiving a clean bill of health. These include those with small aneurysms, and most dramatically, those with large, giant, wide-necked and non-saccular (fusiform) aneurysms.
So let's examine why. When examining the coiling, we note that with maximal packing, the majority of the volume within coiled aneurysms does NOT get filled with embolic material (70-80%). This allows for blood flow to continue into the aneurysm. It is also dangerous to breach the sac of the aneurysm in the first place, so avoidance of aneurysm entry would be optimal. When considering adjunctive stent placement, many stents provide inadequate metal area coverage when deployed. The Neuroform stent itself provides only 6.5-9.5% metal coverage, and so cannot act as a stand-alone therapy.
In comes Chestnut/EV3 with the PED. The PED provides 30-35% metal coverage at maximal expansion, which is obviously much higher coverage. It is deployed just proximal to the neck of the aneurysm in the parent vessel, and thus does not require entry to the aneurysm sac, effectively circumventing accidental perforation. The deployment provides sufficient coverage to physiologically exclude the lesion from circulation, yet is porous enough to preserve the patency of branch vessels covered by the construct. The really cool thing about it is that not only does it effectively occlude aneurysm blood flow (>90% reach full occlusion by the 6-month followup), it facilitates the growth of normal vasculature in the region - "the stent implantation may change the configuration of the parent vessel, changing the anatomy of the parent vessel-aneurysm complex and the aneurysm inflow zone...implantation of the stent within the affected vessel ideally acts as a stimulus and provides a scaffolding to support neointimal overgrowth across the aneurysm neck defect, thereby facilitating the biological remodeling of the deficient segment of the parent artery".
One of the most incredible things is that the PED can act as a stand-alone therapy (15/17 aneurysms in rabbits achieved complete occlusion with only one PED deployed). This may represent a paradigm shift from coiling to stand-alone stenting in the future. From an economical perspective, it will be much cheaper to perform this, both on the basis of materials required (one-three stents vs. ten coils +/- adjunctive stents) and on radiologist time spent in procedure.
With all new products, there are obviously limitations. Placement of the PED precludes future coiling because it blocks neck access, therefore the suggestion has been to jail a microcatheter in the event that re-entry is required. There is also no clear evidence to show how PED affect bifurcation aneurysms, and if occlusion of one side will increase flow to the next one. Lastly, there is dual antiplatelet therapy required during the procedure (aspirin and clopidogrel), which is obviously contraindicated for the context of acute subarachnoid hemorrhage.
Nonetheless, the PED invites a new way to look at cerebral vasculature intervention, and shows that even today companies are still paving the way towards new technologies to aid those afflicted by disease. I think the most exciting thing is that this is no band-aid solution - the PED acts not only to cut off blood flow to the aneurysm, but it also encourages the growth of appropriate vasculature through its scaffolding. HOW FREAKING COOL.
You can read the original papers by clicking on the titles of the papers below:
***
Lylyk, P., Miranda, C., Ceratto, R., Ferrario, A., Scrivano, E., Luna, H. R., et al. (2009) Curative Endovascular Reconstruction of Cerebral Aneurysms with the Pipeline Embolization Device: The Buenos Aires Experience. Neurosurgery, 64(4), 632-643.
Fiorella, D., Woo, H. H., Albuquerque, F. C., & Nelson, P. K. (2008). Definitive Reconstruction of Circumferential, Fusiform Intracranial Aneurysms with the Pipeline Embolization Device. Neurosurgery, 62(5), 1115-1121.
7.18.2009
clinic pt. 6
A very interesting case came through neuro today that I'd really like to share. An elderly individual with a sclerotic right internal carotid artery came in today for a routine stent and angioplasty. The procedure seems to be going fine - the stent is put in place and the plasty works out well to alleviate the 75% blockage, so he finishes up and the nurses begin their assessments.
Immediately it's evident that something is not right. The patient displays left side paralysis of the arm and is showing facial asymmetry. Speech is slurred, probably due to paralysis of facial muscles. Immediately the doctor begins doing some perfusion tests to see if there are any arteries that have been occluded - the ultrasound done prior to the stent and plasty showed the sclerotic plaque to be soft with no calcification and it's possible that while stenting/plasty-ing, some fat could have broken off, evaded the filter wire and embolized in a smaller artery.
After injecting contrast in various areas, it doesn't appear apparent that there is any blockade. It is very clear though that the patient is stroking, so an MR and a CT scan are both ordered, the former for its detail and the latter in case the patient is hemorrhaging.
The story has a happy ending though. Patient went down to the ABACUS for an MR and the nurses down their ran their screening protocols and the patient went from being paralytic to simply showing hemiparesis. Within an hour he was squeezing away and speaking normally so it was simply a transient ischemic attack. It is still worrisome to note that most TIAs will eventually lead to a full stroke, so while this patient is safe for today, his future is at stake. I guess when we're doing interventions we often forget complications are always at hand, especially when the patient has gone back to his room and we don't see what eventually happens to them because we are just involved in a minute but integral part of their care.
In an separate note, it often makes you wonder as to how important these elective procedures are in the grand scheme of things. My friend Shane suggested an interesting article written by the ever-controversial professed utilitarian Peter Singer, who writes about the need to ration health care; spoken like a true economist. Read the article by clicking on the image below:
The article is extremely provoking and obviously offers some ethical dilemmas but his logic is interesting, even if he is abrasive and frustrating. While I've moved strongly towards thinking deontologically, my utilitarian past still nudges me in the ribs and I sometimes find myself thinking about where he's coming from and if it's actually valid. Keep your eye out for the prostitute joke, it's hilarious.
Immediately it's evident that something is not right. The patient displays left side paralysis of the arm and is showing facial asymmetry. Speech is slurred, probably due to paralysis of facial muscles. Immediately the doctor begins doing some perfusion tests to see if there are any arteries that have been occluded - the ultrasound done prior to the stent and plasty showed the sclerotic plaque to be soft with no calcification and it's possible that while stenting/plasty-ing, some fat could have broken off, evaded the filter wire and embolized in a smaller artery.
After injecting contrast in various areas, it doesn't appear apparent that there is any blockade. It is very clear though that the patient is stroking, so an MR and a CT scan are both ordered, the former for its detail and the latter in case the patient is hemorrhaging.
The story has a happy ending though. Patient went down to the ABACUS for an MR and the nurses down their ran their screening protocols and the patient went from being paralytic to simply showing hemiparesis. Within an hour he was squeezing away and speaking normally so it was simply a transient ischemic attack. It is still worrisome to note that most TIAs will eventually lead to a full stroke, so while this patient is safe for today, his future is at stake. I guess when we're doing interventions we often forget complications are always at hand, especially when the patient has gone back to his room and we don't see what eventually happens to them because we are just involved in a minute but integral part of their care.
In an separate note, it often makes you wonder as to how important these elective procedures are in the grand scheme of things. My friend Shane suggested an interesting article written by the ever-controversial professed utilitarian Peter Singer, who writes about the need to ration health care; spoken like a true economist. Read the article by clicking on the image below:
The article is extremely provoking and obviously offers some ethical dilemmas but his logic is interesting, even if he is abrasive and frustrating. While I've moved strongly towards thinking deontologically, my utilitarian past still nudges me in the ribs and I sometimes find myself thinking about where he's coming from and if it's actually valid. Keep your eye out for the prostitute joke, it's hilarious.
6.19.2009
superglue for your brain
A few interesting tidbits. Apparently in Emergency, there are patients known as "camels." These individuals behave poorly and consistently spit on health care workers. As a result, a safety mesh is up over their head - basically a thin, loose burlap sack to prevent the individual from contaminating health care workers with possibly diseased bodily fluids.
I heard another story about a patient today who went to the MR for a scan. Scans kept getting this gigantic artifact across the screen, so one of the techs figured there must have been metal on the person. They went to check for metal electrode leads, such as those in a pacemaker, but couldn't find anything. They ran the scan again and the artifact was still there, so the tech removed the armboards and the headrest, thinking there might be some metal in it. The artifact still remained. Thinking it might be something on the scanner, they removed the patient and ran a quick test scan, but there was no artifact! The tech asked the patient who was both groggy and old, who stated he once had a barium milkshake. The tech thus concluded the barium was the source of the artifact, that the metal must have been interfering with the scan.
It turned out the patient's barium milkshake had been over two years ago, and so the techs were left puzzled. Days later, patient visited the OR, where it was discovered that he neglected to mention that he had been eating coins. The metal from the coin bezoar (remember bezoars???) was causing the artifact, and surprisingly hadn't been pulled out of his body and caused massive internal bleeding from the field.
***
I learned a new word today: Nidus. It basically is the medical term for anything resembling a nest. Remember arteriovenous malformations (AVM)? A 10 year old patient was in our clinic the other day with a crazy AVM, and they use this product called the EV3 Onyx Liquid Embolic System to treat it. Basically they send a catheter into the AVM, inject this compound made of ethylene vinyl alcohol, and let it travel throughout the nidus of the AVM. It ends up plugging blood flow and the AVM becomes harmless, degenerating with time; basically a superglue for your brain.
I heard another story about a patient today who went to the MR for a scan. Scans kept getting this gigantic artifact across the screen, so one of the techs figured there must have been metal on the person. They went to check for metal electrode leads, such as those in a pacemaker, but couldn't find anything. They ran the scan again and the artifact was still there, so the tech removed the armboards and the headrest, thinking there might be some metal in it. The artifact still remained. Thinking it might be something on the scanner, they removed the patient and ran a quick test scan, but there was no artifact! The tech asked the patient who was both groggy and old, who stated he once had a barium milkshake. The tech thus concluded the barium was the source of the artifact, that the metal must have been interfering with the scan.
It turned out the patient's barium milkshake had been over two years ago, and so the techs were left puzzled. Days later, patient visited the OR, where it was discovered that he neglected to mention that he had been eating coins. The metal from the coin bezoar (remember bezoars???) was causing the artifact, and surprisingly hadn't been pulled out of his body and caused massive internal bleeding from the field.
***
I learned a new word today: Nidus. It basically is the medical term for anything resembling a nest. Remember arteriovenous malformations (AVM)? A 10 year old patient was in our clinic the other day with a crazy AVM, and they use this product called the EV3 Onyx Liquid Embolic System to treat it. Basically they send a catheter into the AVM, inject this compound made of ethylene vinyl alcohol, and let it travel throughout the nidus of the AVM. It ends up plugging blood flow and the AVM becomes harmless, degenerating with time; basically a superglue for your brain.
6.18.2009
triage troubles
It is a well known fact that quite often bloggers need to rack their brains to find a topic of discussion for their daily post. That's why I really enjoy days like today, where I encountered such an amazing set of cases at work that I really don't have enough space to talk about it all.
A patient was flown in from southeast Edmonton today and found their way to our unit on an ASAP call. The history is quite fascinating - two days ago this patient (whom I will refer to as 'X') presented to a Medicenter with an earache - doctor concluded it was an ear infection, prescribed run of the mill antibiotics and sent the patient home. In the wee hours of this morning, patient started having difficulties focusing and began to receive a blistering headache. The patient went to the neighbour's house and asked them to call the health authorities because 'X' couldn't remember the number.
Patient was transported sirens and lights to the local hospital emergency where 'X' waited in triage for hours. I was reading the nurse's notes. 6:30 AM patient was stable. 8:10 AM patient began to show obvious signs that something was wrong - left side hemiparesis (weakness), left pupil fixation, worsening headache, slurred speech. By 8:30 AM the patient had depreciated considerably and was immediately sent to CT, where a temporo-occipital intracranial hemorrhage (ICH) was noted. 'X' was immediately sent to U of A hospital's OR, undergoing a unilateral decompressive craniectomy (removal of the skull bone on one side to allow a drop in intracranial pressure (ICP)).
When we received 'X', the symptoms were classical of right side temporo-occipital ICH: 'Worst headache ever' presentation, left sided visual issues, some degree of memory loss, left side hemiparesis, speech pattern abnormalities, and depressed breathing rate due to possible brainstem compression. Scans showed an obvious venous sinus thrombosis developing/developed with the midline being shifted to the left due to ICP. We don't usually do interventional neuroangiography on Thursdays, but this case so obviously needed to be fixed that our radiologists didn't hesitate to jump in.
We have this device called the Penumbra Separator which basically is a clot-sucker. We used a microcatheter and sent it up via the venous system and basically attempted to debulk the clot using the separator. Basically what happens is suction occurs to pull out the clot from the vessel, and the separator is used to poke and claw at the clot to break it up, hopefully allowing suction to remove the clot and improve circulation. We watched for about half an hour as the radiologists attempted this technique to limited success - angiography photos showed the contrast moving rather turbulently through the vessels, only slightly improving circulation through the right venous drainage. They continued this way till about 20 minutes past the end of my shift (I was so interested I stayed longer to watch), and talk was starting about possibly using angioplasty to compress the clot (they inflate a balloon to push the clot against the sides of the vessel wall).
There are a number of crazy things about this case that become very obvious. One of them is the blatant issues with our triage system, which failed to send an extremely critical patient to the CT immediately. Instead, this patient sits around until their assessment is basically in a life or death situation until they act. The patient declined from an 11 to a 9 in the Glasgow Coma Scale (GCS) on the way to the U of A hospital, a scale that measures level of consciousness. Basically, anything less than 8 is a certified coma, so 9 is as low as you can get without the patient being completely unconscious.
Second, this can happen to anyone. Patient was an adult in their mid-30s and an avid marathon runner. The doctors postulate that the cause of the clotting was because of oral contraceptives, which are known to increase the chances of clotting. While clotting can occur anywhere, it was very unfortunate that this developed cerebral-ly for this patient. The timeline is so dramatic - in two hours the patient depreciates considerably, showing that every minute counts in neurological interventions.
I'm looking forward to tomorrow - my nurse friend at work is going to tell me what ended up happening with the patient when I see him tomorrow. I can only pray that everything went well, but the sad fact is that cases like this get ignored so often due to their lack of dramatic presentation at the start of their distress. Patients complaining of headaches are simply thrown on the CT list and wait their turn. By the time the patient has declined, it may already be too late to save them. I can only hope that this patient gets revascularization to the right side of their brain with minimal brain damage occurring.
A patient was flown in from southeast Edmonton today and found their way to our unit on an ASAP call. The history is quite fascinating - two days ago this patient (whom I will refer to as 'X') presented to a Medicenter with an earache - doctor concluded it was an ear infection, prescribed run of the mill antibiotics and sent the patient home. In the wee hours of this morning, patient started having difficulties focusing and began to receive a blistering headache. The patient went to the neighbour's house and asked them to call the health authorities because 'X' couldn't remember the number.
Patient was transported sirens and lights to the local hospital emergency where 'X' waited in triage for hours. I was reading the nurse's notes. 6:30 AM patient was stable. 8:10 AM patient began to show obvious signs that something was wrong - left side hemiparesis (weakness), left pupil fixation, worsening headache, slurred speech. By 8:30 AM the patient had depreciated considerably and was immediately sent to CT, where a temporo-occipital intracranial hemorrhage (ICH) was noted. 'X' was immediately sent to U of A hospital's OR, undergoing a unilateral decompressive craniectomy (removal of the skull bone on one side to allow a drop in intracranial pressure (ICP)).
When we received 'X', the symptoms were classical of right side temporo-occipital ICH: 'Worst headache ever' presentation, left sided visual issues, some degree of memory loss, left side hemiparesis, speech pattern abnormalities, and depressed breathing rate due to possible brainstem compression. Scans showed an obvious venous sinus thrombosis developing/developed with the midline being shifted to the left due to ICP. We don't usually do interventional neuroangiography on Thursdays, but this case so obviously needed to be fixed that our radiologists didn't hesitate to jump in.
We have this device called the Penumbra Separator which basically is a clot-sucker. We used a microcatheter and sent it up via the venous system and basically attempted to debulk the clot using the separator. Basically what happens is suction occurs to pull out the clot from the vessel, and the separator is used to poke and claw at the clot to break it up, hopefully allowing suction to remove the clot and improve circulation. We watched for about half an hour as the radiologists attempted this technique to limited success - angiography photos showed the contrast moving rather turbulently through the vessels, only slightly improving circulation through the right venous drainage. They continued this way till about 20 minutes past the end of my shift (I was so interested I stayed longer to watch), and talk was starting about possibly using angioplasty to compress the clot (they inflate a balloon to push the clot against the sides of the vessel wall).
There are a number of crazy things about this case that become very obvious. One of them is the blatant issues with our triage system, which failed to send an extremely critical patient to the CT immediately. Instead, this patient sits around until their assessment is basically in a life or death situation until they act. The patient declined from an 11 to a 9 in the Glasgow Coma Scale (GCS) on the way to the U of A hospital, a scale that measures level of consciousness. Basically, anything less than 8 is a certified coma, so 9 is as low as you can get without the patient being completely unconscious.
Second, this can happen to anyone. Patient was an adult in their mid-30s and an avid marathon runner. The doctors postulate that the cause of the clotting was because of oral contraceptives, which are known to increase the chances of clotting. While clotting can occur anywhere, it was very unfortunate that this developed cerebral-ly for this patient. The timeline is so dramatic - in two hours the patient depreciates considerably, showing that every minute counts in neurological interventions.
I'm looking forward to tomorrow - my nurse friend at work is going to tell me what ended up happening with the patient when I see him tomorrow. I can only pray that everything went well, but the sad fact is that cases like this get ignored so often due to their lack of dramatic presentation at the start of their distress. Patients complaining of headaches are simply thrown on the CT list and wait their turn. By the time the patient has declined, it may already be too late to save them. I can only hope that this patient gets revascularization to the right side of their brain with minimal brain damage occurring.
6.04.2009
clinic pt. 5
We have three rooms in Angio, aptly named Room 1, Room 2 and Room 3. Room 1 and Room 2 are generally used for body angiography, while Room 3 is typically cerebral angiograms or spinal procedures. I was passing through Room 2 today doing my usual inventory check when the UNE in our area, Marisa, was trying to calm a patient down. The patient kept asking her to hold her hand, likely because she was frightened and just needed a hand to hold, but Marisa was gowned and as per proper aseptic technique, could not touch the patient. She kept telling the patient this, but was met only with, "Hold my hand."
One thing led to another, and I ended up holding this patient's hand. Cold, elderly hands, thin and bony, quivering with a weak grip. This is something so trivial, yet I felt like out of all the days I have been in Angio, this was the most fulfilling.
This is not patient care but it is human comfort. We just need to be told, "It's okay, we'll get through this" once in a while just so we can feel ready to proceed with whatever comes next. Sometimes the best message is one that doesn't use any words.
The doctor came in later and spouted that this patient was such a baby and that "Kind Joey offered his hand to hold," in the typical way that jaded health professionals blow off most non-work related minutiae. I think that for them it probably isn't very important, and I can understand that. For me, being at the lowest rung of the ladder, I have to say that my own psychological state was strongly bolstered by this interaction. For some reason that is unknown to me, I do feel good, even though I didn't administer any tangible health care at all.
One thing led to another, and I ended up holding this patient's hand. Cold, elderly hands, thin and bony, quivering with a weak grip. This is something so trivial, yet I felt like out of all the days I have been in Angio, this was the most fulfilling.
This is not patient care but it is human comfort. We just need to be told, "It's okay, we'll get through this" once in a while just so we can feel ready to proceed with whatever comes next. Sometimes the best message is one that doesn't use any words.
The doctor came in later and spouted that this patient was such a baby and that "Kind Joey offered his hand to hold," in the typical way that jaded health professionals blow off most non-work related minutiae. I think that for them it probably isn't very important, and I can understand that. For me, being at the lowest rung of the ladder, I have to say that my own psychological state was strongly bolstered by this interaction. For some reason that is unknown to me, I do feel good, even though I didn't administer any tangible health care at all.
5.29.2009
funny story/unfunny story
Somebody came to the unit today and accosted me with a thick accent: "Do you have Kelly?" I said, "Sure, I'll just be a second." I ran over to the main scrub room and found Kelly and said, "Somebody's looking for you," and took her to the hall where the man was waiting. "Here you go," I said.
"No!" the main replied, "Like kelly scissors!"
"Oh."
They laughed.
***
Unhappy news for all the Diagnostic Imaging individuals like me. Apparently the Harper government is going to be selling some federally owned nuclear reactors, the ones that specialize in making radioisotopes used for medical imaging. Hospitals who obtain their products from these suppliers at partially gov't subsidized costs will soon find a private market out there. I'm guessing there aren't too many companies out there that make radioisotopes, esp. given the short half-life and cost of the materials, so privatization means higher cost for health care supplies.
At a time where Liepert is making cuts and fiscal vigilance is undoubtedly a necessity, this is not good news. Nurses and administrators on my unit are already starting to feel the strain and tension - nobody's job is safe unless they're really high up. The axe even fell upon me recently - I was under the impression that I would have a full time job this summer, a 40 hour week schedule. From what my supervisor was telling me, they were really excited to hire me and were happy to supplement me with hours a month ago. Unfortunately, a lot can happen in a month. Pressure has come down upon managers to cut costs, and so in retaliation they are forced to tell employees to not take overtime, to regulate all expenditures, and freeze all employee hiring. If you take a look at the AHS hiring board near Bernard Snell Hall, the entire case is completely empty.
Anyhow, like I said, the axe fell upon me recently. I've now been reduced to only working 2 days a week, so I guess I have to find another part time job. This is scary stuff - job losses, no hospital beds and health care strain are all very, very real possibilities at the moment. And at the way it stands, this is just the beginning of a nightmare paving the way for a Ralph Klein-era style health care system disaster in the near future. Scary stuff.
"No!" the main replied, "Like kelly scissors!"
"Oh."
They laughed.
***
Unhappy news for all the Diagnostic Imaging individuals like me. Apparently the Harper government is going to be selling some federally owned nuclear reactors, the ones that specialize in making radioisotopes used for medical imaging. Hospitals who obtain their products from these suppliers at partially gov't subsidized costs will soon find a private market out there. I'm guessing there aren't too many companies out there that make radioisotopes, esp. given the short half-life and cost of the materials, so privatization means higher cost for health care supplies.
At a time where Liepert is making cuts and fiscal vigilance is undoubtedly a necessity, this is not good news. Nurses and administrators on my unit are already starting to feel the strain and tension - nobody's job is safe unless they're really high up. The axe even fell upon me recently - I was under the impression that I would have a full time job this summer, a 40 hour week schedule. From what my supervisor was telling me, they were really excited to hire me and were happy to supplement me with hours a month ago. Unfortunately, a lot can happen in a month. Pressure has come down upon managers to cut costs, and so in retaliation they are forced to tell employees to not take overtime, to regulate all expenditures, and freeze all employee hiring. If you take a look at the AHS hiring board near Bernard Snell Hall, the entire case is completely empty.
Anyhow, like I said, the axe fell upon me recently. I've now been reduced to only working 2 days a week, so I guess I have to find another part time job. This is scary stuff - job losses, no hospital beds and health care strain are all very, very real possibilities at the moment. And at the way it stands, this is just the beginning of a nightmare paving the way for a Ralph Klein-era style health care system disaster in the near future. Scary stuff.
5.26.2009
clinic pt. 4
It seems we have a thief in our midst. We have a medicine cabinet on our unit that is well stocked and also well locked to prevent drug seekers and common crooks from perusing our sedative resources. Unfortunately, management brought a locksmith to that area this morning to discuss how somebody managed to jimmy open the lock over the weekend and snag some fentanyl, an opoid with many times more the potency of morphine. The locks they have on the unit are deemed to be "unpick-able" by our resident locksmith, which begs the question that perhaps the thief is either extremely smart, somebody left a key lying around, or someone on our unit has a secret drug habit.
In other news, it always fascinates me how human patients are. Of course I know they're humans, but it's so easy to just treat them as a case number or as another procedure passing through. Here they are being wheeled down the hall hand-in-hand with their best friend, who waits faithfully in the stretcher bay beside the empty bed filled with stuffed animals, as her counterpart gets a catheter stuck in their kidney. As I was taking some dirty linens to the supply room to drop off for laundry services, a patient lying in the stretcher bay called my attention. He told me that he had been waiting for over an hour for somebody to come pick him up and take him back to his room, and that he was getting both impatient and uncomfortable. I don't usually get much client interaction (most of the patients are sedated and just lie there when I'm called around), so I actually, for once, felt useful. All I was doing was simply addressing this man's needs - a man's needs, not a patient's. I relayed info that yes, he had been sitting there for a long time and we know he's been there, but porters are backed up and as soon as they're ready we'll have him on his way. I just think it's the human side of us worrying about people neglecting and abandoning us, especially in a novel and rather scary environment like the hospital bay. I think just being able to relate to that made this encounter very personal, even though it was fairly trivial. All he wanted to know was that we hadn't forgotten about him.
While it's obviously important to realize that patients are humans too, we had a rather bizarre case today that makes you wonder how human the patient actually is. Let me elaborate. A client with a meningioma (a tumour in the meninges, the layers covering the brain) came in for a cerebral angiogram, and seemed to be quite comfortable with the proceedings of the pre-op.
(Note the white coloured meningioma on the left frontotemporal side. The large mass causes displacement of the surrounding tissue, most obviously noted by the squishing of the ventricles, the black moon shapes in the middle indicated by the central red arrow. The right one is more normal.)
We transferred the patient over to the table and readied for the procedure. When everything seemed like it was going swimmingly, all of a sudden the patient sits up quickly, head banging into our Siemens angiography system, exclaiming that today didn't seem like a good day for the procedure.
Now at this point, I began to wonder what was the contributing factor to this sudden outburst. Was this purely fear? Did the patient suddenly feel overwhelmed with claustrophobia or trypanophobia or the abrupt realization that they just couldn't stand doing it? It's only a natural reaction for humans to bolt in a moment where they feel cornered, threatened - it's both instinctual and evolutionary.
At the same time, I began to wonder what portion of this behaviour was purely pathology. The patient came to the room almost half an hour late, managing to wander off in search of a bathroom and ending up halfway across the hospital. This was the second time in the last few days this was accomplished, so I began to ponder whether compression from the tumour was resulting in deficiencies in orientation and possibly even judgment. Could this have contributed to the refusal of the procedure? Another indication the patient wasn't all quite there was that the patient kept saying that they were ready for their hysterectomy, and insisted quite heavily that this procedure was what the patient was in Neurovascular for.
Sometimes it's hard to determine whether to call a neurologist or a relative over, whether to cite pathology or jitters. Either way, at the end of the day, no means no. We didn't follow through with the procedure, and the patient went back to their room to await another day.
In other news, it always fascinates me how human patients are. Of course I know they're humans, but it's so easy to just treat them as a case number or as another procedure passing through. Here they are being wheeled down the hall hand-in-hand with their best friend, who waits faithfully in the stretcher bay beside the empty bed filled with stuffed animals, as her counterpart gets a catheter stuck in their kidney. As I was taking some dirty linens to the supply room to drop off for laundry services, a patient lying in the stretcher bay called my attention. He told me that he had been waiting for over an hour for somebody to come pick him up and take him back to his room, and that he was getting both impatient and uncomfortable. I don't usually get much client interaction (most of the patients are sedated and just lie there when I'm called around), so I actually, for once, felt useful. All I was doing was simply addressing this man's needs - a man's needs, not a patient's. I relayed info that yes, he had been sitting there for a long time and we know he's been there, but porters are backed up and as soon as they're ready we'll have him on his way. I just think it's the human side of us worrying about people neglecting and abandoning us, especially in a novel and rather scary environment like the hospital bay. I think just being able to relate to that made this encounter very personal, even though it was fairly trivial. All he wanted to know was that we hadn't forgotten about him.
While it's obviously important to realize that patients are humans too, we had a rather bizarre case today that makes you wonder how human the patient actually is. Let me elaborate. A client with a meningioma (a tumour in the meninges, the layers covering the brain) came in for a cerebral angiogram, and seemed to be quite comfortable with the proceedings of the pre-op.
(Note the white coloured meningioma on the left frontotemporal side. The large mass causes displacement of the surrounding tissue, most obviously noted by the squishing of the ventricles, the black moon shapes in the middle indicated by the central red arrow. The right one is more normal.)
We transferred the patient over to the table and readied for the procedure. When everything seemed like it was going swimmingly, all of a sudden the patient sits up quickly, head banging into our Siemens angiography system, exclaiming that today didn't seem like a good day for the procedure.
Now at this point, I began to wonder what was the contributing factor to this sudden outburst. Was this purely fear? Did the patient suddenly feel overwhelmed with claustrophobia or trypanophobia or the abrupt realization that they just couldn't stand doing it? It's only a natural reaction for humans to bolt in a moment where they feel cornered, threatened - it's both instinctual and evolutionary.
At the same time, I began to wonder what portion of this behaviour was purely pathology. The patient came to the room almost half an hour late, managing to wander off in search of a bathroom and ending up halfway across the hospital. This was the second time in the last few days this was accomplished, so I began to ponder whether compression from the tumour was resulting in deficiencies in orientation and possibly even judgment. Could this have contributed to the refusal of the procedure? Another indication the patient wasn't all quite there was that the patient kept saying that they were ready for their hysterectomy, and insisted quite heavily that this procedure was what the patient was in Neurovascular for.
Sometimes it's hard to determine whether to call a neurologist or a relative over, whether to cite pathology or jitters. Either way, at the end of the day, no means no. We didn't follow through with the procedure, and the patient went back to their room to await another day.
5.14.2009
clinic pt. 3; of mice and of men
A subarachnoid hemorrhage patient came in today, the first I've ever encountered actually. Subarachnoid hemorrhages are bleeds occuring under the second layer, the arachnoid mater, covering the brain. It's funny because you often think that right below your skull is just your brain, shining and glistening, but that's not true, it's protected by three layers:
Skull
-----
Dura mater (tough, leathery)
-----
Arachnoid mater (thin, webby)
-----
Pia mater (v. thin, attached to brain)
Subarachnoid hemorrhages are interesting in that when bleeding occurs under this layer, it tends to bleed in a way that covers the whole brain rather than to bleeding just into one area and creating a pool of blood. Postmortem patients that had subarachnoid bleeds have brains that are all red because the layer allows the blood to spread diffusely through the cerebrospinal fluid. Patient had a CT which allows for confirmation of the bleed (CT scans allow blood to show up very clearly as being whiter - a subarachnoid bleed makes the whole brain look blurry), and then came to our unit for an angio just to confirm the source of the bleed. It was an aneurysm, much like this case:
We also had something I haven't seen before, which was a T9 facet joint injection. Basically this means that you stick a needle with a mixture of two medications (Marcaine - an anesthetic that acts on short term, Depo-medrol - a steroid that promotes healing in the long term) into the spaces between injured spinal area. I found it strange that the patient is lying there with a needle sticking out of his back as if he had just been stabbed.
After work, I got to go over to Dr. Kar's lab and shadow one of the research students. Little did I know that this was what I got to witness:
There were a bunch of mice in this cage looking really cute, which is saying a lot because I hate mice or rats or any rodent, really. I go, "Cute!" and she says, "No, don't get attached." She then picks up a mouse and puts it in this jar of anesthetic that promptly knocks it out. Then she pulls it out and stretches it out on its back like in the picture, and pours anesthetic down its throat, just in case. Using a pair of scissors, she slices open the stomach, and its entrails come pouring out. She carefully removes the ovaries, then, quite surgically, snips off the mouse's head.
I was fascinated because dissections are really neat, but at the same time, if it was me holding those scissors, I'm not really even sure I could do it. And even if I did, is that a part of me, morally, that is dying? Even though the mouse is completely anesthetized and probably feels no pain, it still begs the question that there is no real humane way to kill anything. Killing is killing, and I'm not sure where I stand on the issue. Hopefully I won't have to do any mice dissections?
Anyways, she then took the ovaries, put them in a dish, and then carefully opened them up with a scalpel. She removed the tiny mice growing in the ovaries, cut their heads off, then transferred them to another dish. She then cut their heads open to reveal their brains, then took them over to the microscope so she could dissect out the hippocampus in order to do neuronal cell cultures.
What a day.
***
In other news, the sleeper movie of this year, watch it:
Kate Beckinsale, Matt Dillon, David Schwimmer, Angela Bassett in a courtroom thriller about a reporter who has revealed a CIA agent. She opposes the federal court when they ask her to reveal the name of her source, and she refuses, which is essentially treason. As a result, she is jailed.
The movie is slow, but amazing on many levels. There's a speech delivered about 4/5ths through the movie by her attorney that is one of the best speeches I've heard in a movie, ever. There's also the mother of all twist endings that is guaranteed to floor. If you're heading to the rental place and are looking for something, better to watch this, it definitely beats Twilight. I'm so surprised movies like this go straight-to-DVD when they deserve to be on the podium.
Enjoy your long weekend.
Skull
-----
Dura mater (tough, leathery)
-----
Arachnoid mater (thin, webby)
-----
Pia mater (v. thin, attached to brain)
Subarachnoid hemorrhages are interesting in that when bleeding occurs under this layer, it tends to bleed in a way that covers the whole brain rather than to bleeding just into one area and creating a pool of blood. Postmortem patients that had subarachnoid bleeds have brains that are all red because the layer allows the blood to spread diffusely through the cerebrospinal fluid. Patient had a CT which allows for confirmation of the bleed (CT scans allow blood to show up very clearly as being whiter - a subarachnoid bleed makes the whole brain look blurry), and then came to our unit for an angio just to confirm the source of the bleed. It was an aneurysm, much like this case:
We also had something I haven't seen before, which was a T9 facet joint injection. Basically this means that you stick a needle with a mixture of two medications (Marcaine - an anesthetic that acts on short term, Depo-medrol - a steroid that promotes healing in the long term) into the spaces between injured spinal area. I found it strange that the patient is lying there with a needle sticking out of his back as if he had just been stabbed.
After work, I got to go over to Dr. Kar's lab and shadow one of the research students. Little did I know that this was what I got to witness:
There were a bunch of mice in this cage looking really cute, which is saying a lot because I hate mice or rats or any rodent, really. I go, "Cute!" and she says, "No, don't get attached." She then picks up a mouse and puts it in this jar of anesthetic that promptly knocks it out. Then she pulls it out and stretches it out on its back like in the picture, and pours anesthetic down its throat, just in case. Using a pair of scissors, she slices open the stomach, and its entrails come pouring out. She carefully removes the ovaries, then, quite surgically, snips off the mouse's head.
I was fascinated because dissections are really neat, but at the same time, if it was me holding those scissors, I'm not really even sure I could do it. And even if I did, is that a part of me, morally, that is dying? Even though the mouse is completely anesthetized and probably feels no pain, it still begs the question that there is no real humane way to kill anything. Killing is killing, and I'm not sure where I stand on the issue. Hopefully I won't have to do any mice dissections?
Anyways, she then took the ovaries, put them in a dish, and then carefully opened them up with a scalpel. She removed the tiny mice growing in the ovaries, cut their heads off, then transferred them to another dish. She then cut their heads open to reveal their brains, then took them over to the microscope so she could dissect out the hippocampus in order to do neuronal cell cultures.
What a day.
***
In other news, the sleeper movie of this year, watch it:
Kate Beckinsale, Matt Dillon, David Schwimmer, Angela Bassett in a courtroom thriller about a reporter who has revealed a CIA agent. She opposes the federal court when they ask her to reveal the name of her source, and she refuses, which is essentially treason. As a result, she is jailed.
The movie is slow, but amazing on many levels. There's a speech delivered about 4/5ths through the movie by her attorney that is one of the best speeches I've heard in a movie, ever. There's also the mother of all twist endings that is guaranteed to floor. If you're heading to the rental place and are looking for something, better to watch this, it definitely beats Twilight. I'm so surprised movies like this go straight-to-DVD when they deserve to be on the podium.
Enjoy your long weekend.
5.11.2009
clinic
I just started work last week in the Interventional Neurovascular Unit at the hospital, a subgroup within Radiology & Diagnostic Imaging, and I have to say that being in the clinic is a completely different experience from learning in the book. Reading papers is fantastic when you're just studying the theory behind it, but when it comes to actual intervention, knowing how to roll a patient properly holds much more weight than knowing the physiology of why heparin works.
Irregardless of my lack of clinical prowress, I've seen some really interesting things the last few days. We do a lot of angiograms where I work, which allows for visualization of the vessels in the brain. Our unit takes X-ray pictures of the vasculature using a contrast agent to show the vessels, and then using this data, we can recreate a 3D image that can be manipulated, spun, and measured to plan surgical treatment.
I got to see a patient with a MASSIVE berry aneurysm coupled by two smaller aneurysms. An aneurysm is essentially a bubble in a blood vessel due to wall weakening, which is extremely dangerous. It's basically a time bomb - the overly dilated vessel itself does nothing on its own, but can rupture at any point in time, causing inter-brain hemorrhage that quickly can result in death. I've seen some textbook photos of aneurysms, but nothing so big as what I saw on that screen.
I also got to witness an ateriovenous malformation (AVM). Blood vessels typically grow in a regularly spaced fashion, but individuals with AVMs have abnormally growing vessels that become almost neoplastic in nature. These people have massive clumps of vessels that provide inadequate blood circulation to the areas of the brain that require perfusion.
Today, I also got to see another aneurysm, but what was more interesting was that the patient just had a craniotomy (they open up the skull to expose the brain), and her forehead was stapled shut. She had this hairband of staples to close the surgical wound, and on the scans you could see this snowflake-shaped material clearly in contrast to the rest of the image. I asked one of the nurses what it was, and she told me that they were surgical clamps, permanent pieces of metal embedded in the skulls to hold the bone in place after craniotomies.
What I find most fascinating is that these patients who have severe brain abnormalities are completely intact cognitively - they can converse and laugh and grumble about how it takes so long for procedures to start. They are absolutely able to function normally, albeit with minor seizures or headaches, even though they have this time bomb in their head that might kill them or utterly incapacitate them at any point in time. It's almost a sad story, but I suppose the best kind of disease, apart from having no disease, is one that doesn't affect you until the moment before you die.
Irregardless of my lack of clinical prowress, I've seen some really interesting things the last few days. We do a lot of angiograms where I work, which allows for visualization of the vessels in the brain. Our unit takes X-ray pictures of the vasculature using a contrast agent to show the vessels, and then using this data, we can recreate a 3D image that can be manipulated, spun, and measured to plan surgical treatment.
I got to see a patient with a MASSIVE berry aneurysm coupled by two smaller aneurysms. An aneurysm is essentially a bubble in a blood vessel due to wall weakening, which is extremely dangerous. It's basically a time bomb - the overly dilated vessel itself does nothing on its own, but can rupture at any point in time, causing inter-brain hemorrhage that quickly can result in death. I've seen some textbook photos of aneurysms, but nothing so big as what I saw on that screen.
I also got to witness an ateriovenous malformation (AVM). Blood vessels typically grow in a regularly spaced fashion, but individuals with AVMs have abnormally growing vessels that become almost neoplastic in nature. These people have massive clumps of vessels that provide inadequate blood circulation to the areas of the brain that require perfusion.
Today, I also got to see another aneurysm, but what was more interesting was that the patient just had a craniotomy (they open up the skull to expose the brain), and her forehead was stapled shut. She had this hairband of staples to close the surgical wound, and on the scans you could see this snowflake-shaped material clearly in contrast to the rest of the image. I asked one of the nurses what it was, and she told me that they were surgical clamps, permanent pieces of metal embedded in the skulls to hold the bone in place after craniotomies.
What I find most fascinating is that these patients who have severe brain abnormalities are completely intact cognitively - they can converse and laugh and grumble about how it takes so long for procedures to start. They are absolutely able to function normally, albeit with minor seizures or headaches, even though they have this time bomb in their head that might kill them or utterly incapacitate them at any point in time. It's almost a sad story, but I suppose the best kind of disease, apart from having no disease, is one that doesn't affect you until the moment before you die.
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