Transporters on strike: Understanding strokes.

Brain strokeThere he sits, perched on high. The little control freak, with his pompous attitude, acts like it’s all about him. Barking out orders, he expects, no, he demands, utter and instant obedience. And, what he wants, he gets. Like the CEO of a complex organization, this leader monitors and makes corrections to be certain that his domain and its components function in perfect harmony. In exchange for the minions’ immediate carrying out of his demands, he makes certain they survive the constant barrage of attacks against the unit.

All is well until there is the tiniest of revolts. One of the transporters within the system decides to go on strike. He stops making his deliveries. Then, the vulnerability of the man behind the machine is exposed. Not as pompous as he pretended, he’s actually quite vulnerable.

For all the control the brain exerts over nearly every aspect of our being, it remains dependent on a constant flow of energy and tasty nutrients to do it’s job well. When one of the arteries supplying this ceaseless transport of blood gets blocked, it’s no longer making deliveries. And that, my friends, is when one starts to suffer a stroke. And, when a stroke occurs, nothing seems to work as it was intended.

I see a lot of misconceptions about the symptoms of a stroke as well as and the underlying cause. So, let’s clear that up.

Actually, there are different types of strokes. We’re talking about ischemic strokes. Ischemia is where a part of the body is not getting an adequate supply of blood. If this occurs for too long, that part of the body begins to die. More accurately, the cells in that area not getting blood flow start to die. This can happen not only in the brain, to cause a stroke, but also in the heart (a heart attack), the bowels, the retina, or a limb.

To the brain, blood must be flowing constantly. The supply of oxygen and glucose is vital for even the most mundane of tasks. When a part of the brain does not get that constant flow, we have symptoms of a stroke. These symptoms vary based on which part of the brain is suffering. Sometimes it’s an arm and a leg on one side of the body that stops working normally. Or, there can be a loss of vision, slurred speech, or the inability to talk or to at least find the right word to say. We call that expressive aphasia.  Sometimes a stroke can simply affect our balance, so that we stumble around like we are three sheets to the wind.

Strokes occur when a blood vessel gets blocked by an embolic clot. Embolic means that this clot originated elsewhere and is coursing through arteries which are like pipes that get smaller and smaller until they reach their final destination. The clot is a clump of blood and platelets that wedges itself into a tight little crevice to keep the flowing blood from getting through. It’s like the collection of hair, Legos, and Matchbox cars your plumber had to snake out of your pipes so the toilet would flush. It’s this clot that is the target of the so-called clot-busting drug, tPA.

Now, forever ago, it was commonplace to give this type of medicine to patients having heart attacks, which are also caused by embolic clots. That worked well until the cardiologists figured out how to go in with little catheters and just remove the clot.

While the idea of using tPA on strokes makes sense, it doesn’t work as well as it did for heart attacks. Brain and heart are different. You see, sick brain, like one that isn’t getting enough blood flow, has a tendency to bleed. So your ischemic stroke turns into a hemorrhagic stroke. And, even if there is no bleeding, the brain has a harder time bouncing back from this insult.

In simple terms, if you have a stroke and it’s severe enough, you may be offered this clot-dissolving drug. First, though, you have to get the drug within the first 3 hours of the onset of your symptoms. Sometimes this window of opportunity can be extended to 4.5 hours. If you wake up with stroke-like symptoms, we have to assume those symptoms started all the way back when you fell asleep, because we just don’t know. That excludes a lot of people from getting tPA.

Now, for some numbers. If 100 people get this drug for their stroke, 12 of them will be improve more than if they didn’t get the drug. 6 of the hundred people, though, will have bleeding in their brains. Half of those who bleed will die. Most patients will not do any better or any worse than they would have without the medicine.

Study after study is underway to figure out if the interventional radiologists can go in and just remove the clot. So far, that’s not been perfected. Every day, some new catheter and protocol is being developed to try to make that happen without doing more harm. So far, it’s not ready for prime time.

To increase the confusion, there are things that mimic strokes. Low blood sugar, complex migraines, Bell’s palsy are a few things that come to mind. You see, there has to be some reason you still need us doctors.

Unlike most of my posts, this is not a place to save money. If you notice part of your body revolting against the orders being given by your brain, don’t hold it against the site that’s misbehaving. More than likely, the corpuscles supplying the brain with it’s tasty goodies got log jammed. Don’t wait. Come see us and we’ll figure if a little dynamite is in order to get the pipes flowing again.

Respiratory illness targets 50% of population. Are you at risk?

Sick man wrapped in blanketRecently I wrote about influenza. Influenza is certainly bad news. It’s to be avoided at all cost. For influenza there is not a cure, but at least there is a vaccine.

What doesn’t get a lot of press, until now, is the viral respiratory illness that seeks to decimate half of the planet’s population. With no known cure, and certainly nothing as trendy as a vaccine available, this beast is locked and loaded, targeting any human blessed with a Y chromosome.

Yes, I’m talking about the man cold.

I suppose this plague-like illness is mother nature’s way of evening the score. Men are blessed with larger muscle mass, rational thought, and the ability to get from point A to point B without ever stopping to ask for directions. So, I guess all that awesomeness set us up in the cosmos to be targeted like Jason Bourne in his latest action flick.

Let’s break down the man cold from a medical perspective. Initially, there is the slight sniffle. Maybe a tickle in the throat. We try to ignore that it’s there. Allergies, probably. Then comes the full on runny nose. This sucker is like an upside down geyser, wreaking havoc on the upper lip. There’s nothing you can do for this faucet: it’s immune to over-the-counter medications. All you can do is get the softest, lotion-soaked facial tissue and wipe, wipe, wipe. Eventually this cloud-like cotton feels like sandpaper strapped to a power tool.

As if this assault on all that is masculine is not enough, that scratchy throat sometimes evolves into a cough. Not a cough-up-a-lung cough like pneumonia. More of a post-nasal drip like tiny lemmings leaping to their death down your gullet cough that prohibits you from obtaining any amount of sleep. Couple that with fever and aches that run as deep as your bone marrow, and you’ve got a full-blown man cold. And, once the case progresses to this state, whining is inevitable. We think the whining actually soothes the soul. Maybe it releases some endorphins. The studies are still pending.

YouTube is a great source of education. This video puts into perspective the serious nature of the man cold. Thanks to our friends across the pond.

Women joke about men and their little man colds. Ladies, this is nothing to be scoffed at. There are two reasons women do not often get man colds. First, their congenital Y chromosome deficiency somehow offers protection via immune-modulated pathways, perhaps. Secondly, if a woman happens to get a man cold, it is often fatal and underreported in the lay press. Women reading this: by definition, if you had a cold, and lived to talk about it, it almost certainly was NOT a man cold.

The detriment to society of the man cold is almost incalculable. First, men obviously cannot work while contending with such a devastating illness. At the very minimum, it’s not fair to go into the marketplace and infect other men. Secondly, there is usually the need for someone to mend the man back to health. Women, with their natural inability to become infected with this man-hating virus, function well in the role of caretakers, bringing Tylenol and Advil, warm blankets, chicken noodle soup, and love. Don’t forget the love. That’s key to ensuring a full recovery.

In conclusion, men, I feel your pain. I’ve been there. I’ve been the source of ridicule both at home and in the work place. Persevere. Women, the next time a man you love has a man cold, be thankful you were blessed with two X chromosomes. Show him some sympathy and compassion, with an extra dose of doting, as needed. Doctor’s orders.


Prevent getting hit by a Mack truck. Get vaccinated!

“Yeah, I had the flu yesterday. Much better now.”iStock_000000633147_Medium

“My kid had the stomach flu last week.”

“Man, my throat hurts. I think I’m getting the flu.”

Wrong. All wrong. The word “flu” gets thrown around a ton as a substitute for any of a number of respiratory or GI illnesses. They are not in the same game as The Flu. Not even the same sport. No. These other common ailments? They hear the word influenza and they shudder. Influenza is the T. Rex of the viral world.

I want you to take one thing away from this blog. Influenza: avoid it like the plague.

What’s the big deal? Well, first of all, influenza is very contagious. In fact, you can get it from someone even a day before he has symptoms. You’re infectious for a week after your symptoms start. On top of it, you feel horrible. Not like “my nose is running and my throat is scratchy.” No, more like being dragged behind an RV through the desert would be an improvement in my symptoms. Ok, I’ll admit, I just finished watching Breaking Bad.

So, fever, cough, congestion, body aches, chills, headache, fatigue. I’ve had patients tell me that even just moving their fingers were painful. Did I mention body aches? I consider that to be a hallmark bad symptom of influenza. And fatigue to the point you don’t even want to sit up in bed. Of all the people who come to the ED in their pajamas, these are the ones I might give a pass to.

These are just the walking wounded. Some people get really sick from the flu. Like, fatally sick. We’re not great at predicting who is going to get hit really hard.

This year, we’ve seen a lot of H1N1, the nasty influenza A strain that hit us so hard in the 2009-2010 flu season. Back then, H1N1 caught us off guard. By the time it was identified as traveling over from Asia, as the flu does, it was too late to get it in the vaccine. H1N1 was particularly vicious toward young, healthy people. If you were young, especially pregnant, and had a great immune system, H1N1 caused an exaggerated response of that immune system. There was more inflammation going on in the body, particularly the lungs. This year, as in previous years, we’ve seen fatalities from the flu, including some young, otherwise healthy people.

How do we diagnose it? Mostly I ask about your symptoms. We have rapid tests for influenza, but they aren’t sensitive enough to rule out the disease. If your story fits with influenza this time of year, you probably have influenza. It’s not rocket science.

Now, to let you into the mind of how the emergency physician thinks, what do I look for in the patient I think has influenza? Well, I look to see what other illnesses they have. Immune suppression from diseases or drugs, diabetes, obesity, and extremes of ages (the babies and the octogenarians) are all risks for badness. Then, I look at vital signs. The people who have low oxygen level, rapid breathing, and look sicker than just “I feel horrible” make me worry.

Now, there is antiviral medicine that may be helpful if started in the first 48 hours of the illness, but the data on its effectiveness is not great. If it does help, it probably shortens how long you’re sick by about a day. You’re sick 4-6 days without the medicine. You pay dearly for that 1 day improvement.

Want one more kick in the pants? There is some data that taking fever-reducing drugs like Tylenol and Advil may prolong the duration of your symptoms. If I get influenza, I’m taking some ibuprofen to help with my fever and my aches and pains. I’d rather hurt less for a longer period of time than roll over and let influenza do as it pleases. But, I’m a fighter. You do what you want.

Here’s an idea. How about an ounce of prevention? Yeah, even this far into influenza season it’s not too late to get vaccinated. It’s especially not too late to plan to get your shot this fall. Really, why go through this misery? Yes, sometimes you still get the flu because the vaccine isn’t perfect. But, you don’t get the flu from the vaccine. It just so happens you get vaccinated the time of year all the little wimpy respiratory viruses are going around. The influenza vaccine won’t help you with those. Man up, cupcake. Those are just a symptom of living.

Get vaccinated. You’re much better off using those sick days on a nice spring day when you would rather be kayaking. Shhh… I won’t tell. I’ll probably write you a work note.