Tag Archives: Pain

Intensive Care Views: ‘Pain & Airway Management’

Pain Management in the Intensive Care Unit.

Institution: Department of Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin & Massachusetts General Hospital, Harvard Medical School, Boston

Progressive Disorders: ‘Parkinson’s Disease’

Parkinson’s Disease is a MOVEMENT DISORDER. It is grouped with a number of OTHER NEURODEGENERATIVE illnesses which can show similar symptoms. When Parkinson-like problems are present in other syndromes, it is called PARKINSONISM, to distinguish it from primary Parkinson’s disease.

There is no 100% reliable sign, symptom or diagnostic test; Rather, the gold standard of diagnosis rests on the ability of experienced neurologists to discern a PATTERN of findings which together support the likelihood of Parkinson’s disease. The accuracy is about 80-90%. The 3 characteristic symptoms of PD are BRADYKINESIA, TREMOR, and RIGIDITY. Bradykinesia means SLOW MOVEMENT.

The typical Tremor is a tapping, “pill-rolling” motion that is present at rest, and DISAPPEARS ON MOTION. The Rigidity is pervasive, and patients describe it as trying to move in thick molasses. A “lead-pipe resistance”, stiffness and PAIN in the shoulder may be a first system, and not uncommonly the patient will often go to an Orthopedist or Rheumatologist. Depression, constipation, anosmia and SLEEP Disorders are common in the years leading up to the diagnosis of Parkinson’s Disease, and DEMENTIA frequently develops.

Genetics play a role, and PD can run in Families. Environmental causes such as Trauma and anoxia can injure nerve cells, as can Toxins. MPTP contamination of a drug supply once caused a surge of Parkinsonism. Degeneration of DOPAMINERGIC nerve cells in the Substantia Nigra is the ultimate cause of PD, and accumulation of ALPHA SYNUCLEIN fibrils is a correlate of that degeneration.

Practical treatment at present aims to boost Dopamine. Administration of Levodopa, a DA precursor, if effective, a response helps to confirm the diagnosis. Magnetic and electrical stimulation of the brain have been used. Experimental injections of Dopaminergic cells into the brain is under investigation. Causing Astrocytes to differentiate into dopaminergic cells has been successful in animals.

With Celebrities such as Michael Fox and Robin Williams raising awareness, and the Mechanism understood, I am optimistic that a real cure may be found in a few years.

–Dr. C.

DR. C’S MEDICINE CABINET: Benefits & Risks Of ‘Aspirin’

Aspirin (acetylsalicylic acid) was one of the first medicines constructed, or synthesized, in a chemical laboratory. After 40 years ( medical progress wasn’t too fast in the 19th Century), Bayer investigated it as an alternative to Salicylates, which had been used since antiquity in the form of Willow bark for medical treatment, especially of FEVER and PAIN relief.

It is an understatement to say that it was successful. After almost another century, in 1982, a nobel prize was awarded for the discovery of its mode of action. Its multiplicity of effects, some of them bad, are only now becoming appreciated. My practice in medicine was in Allergic diseases, and I treated many people with nasal, sinus and asthmatic diseases.

It became apparent that, in certain people, aspirin could worsen all 3 conditions, and rhinitis (with Polyps), sinusitis and asthma became known as “Samter’s Triad”, or simply ASPIRIN DISEASE. Believe it or not, the condition can be helped by “aspirin desensitization”, where the Patient was started on tiny doses of aspirin by mouth, which over a period of hours was gradually increased to a normal dose.

I would not try this at home. I sent my patients to a specialized medical center for treatment, Other undesirable effects induce bleeding disorders, stomach ulcers, and, in children, a very serious disease called Reye’s syndrome. The latter is so serious that aspirin is not often given to children; except when it is needed, such as in a condition called Kawasaki’s Disease, where it is very helpful.

I mention these details to counteract the blase attitude created by long use. No longer does the doctor say “Take an aspirin and call me in the morning”. For a long while, low-dose Aspirin was used in most Patients with coronary artery disease, as a method of preventing sudden clot formation. I took 65 mg. Of aspirin for years, even though I had no narrowing of my arteries.

Now it is found that aspirin can cause an excess of Hemorrhagic stroke, and it is not recommended in my age group and risk profile. Aspirin is a powerful medication with a wide variety of effects. Most of its beneficial effects have safer alternatives. Acetaminophen- Tylenol- is now used in place of Aspirin for Pain and fever relief. I suggest not using aspirin unless prescribed by a Doctor.

–Dr. C

THE DOCTORS 101 CHRONIC SYMPTOMS AND CONDITIONS #25: KIDNEY STONES

Kidney stones are more common than you think, and over the span of life, afflict 1 out of 10 people, more commonly men. The pain is sharp, spasmodic and severe; it is described as being worse than the pain of childbirth. The pain is breathtaking, and if you have “renal colic”, your
world is truly “ in a grain of sand”.

This sand, this tiny rock, forms when certain elements and compounds become too concentrated in the urine as it is formed in your kidneys, and “drop out of solution”, or precipitates. This little pebble, which I’m sure feels like a rock, then begins its long, painful journey down the drainage system of the kidneys, and eventually passes, you hope, out with the
urine.

Be sure to save it for analysis if it does. Sometimes it is arrested, causes the urine to “back up”, and you need assistance to get it out. Half of the kidney stone attacks recur, and you will get other attacks.

This is particularly the case if your first attack comes when you are young, or there is a history of kidney stones which runs in your family. It is important for a doctor, such as an internist, to review your case, particularly if you are young.

Your family history, lifestyle including diet, medications, and other problems may give clues which will allow other attacks to be avoided. Sometimes there are serious underlying conditions that should be addressed. Half of people who have kidney stones have a genetic cause, but even here there are lifestyle changes which will help..

Drinking plenty of liquid helps, unless you have kidney failure. Read the Mayo Clinic article referenced below for details. They are interested enough in kidney stones to have consulted a Geologist, the ultimate student of Rocks.

–Dr. C.

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #18: SKIN INFECTIONS

The skin is the protective barrier between the inside of our bodies and the outside world of microorganisms, parasites and toxins. It is often the site of inflammation and infections.

In past times, before the advent of cleanliness and antibiotics, mankind was plagued by erysipelas, boils, carbuncles, and other severe infections of the skin, which are rarely seen now. The beta hemolytic streptococcus and Staphylococcus aureus were ubiquitous in the past, and mostly are contained today.

Severe Infections presently require some skin abnormality, immune deficiency, neglect, animal bite or other breach of skin integrity to be a problem. Antibiotic resistance, however, is allowing some organisms like MERSA to make a comeback.

ECZEMA. or Atopic Dermatitis, was common in my medical practice. This condition weakens the skin barrier, allowing Staphylococcal infection to gain a foothold. In my day, If there were a flare of eczema severity, antibiotics would often help. Leg edema and swelling. such as from heart failure, especially coupled with diabetes and blood vessel disease is also an invitation to infection, such as cellulitis.

Redness, swelling, warmth and pain- the classic rubor, tumor, calor and dolor- as well as swollen local lymph nodes and fever often betray infection of the skin. Please see the recently posted infographic on celulitis.

IMMUNE DEFICIENCY raises the likelihood and risk of severe skin infections. Infection from “flesh-eating bacteria”, often beta hemolytic streptococci in deep tissue planes , is a medical emergency. Immediate surgery is often needed.

Disproportionate PAIN after injury or surgery is often a clue. Certain age groups have characteristic skin infections, such as the scalded skin syndrome of infants, and the acne of adolescents. Viruses, molds, and arthropods can also infect the skin.

Viruses, such as herpes in particular can simulate bacterial infection. Ringworm from fungi is easy to distinguish, but arthropod bites, and especially bee sting can look very much like bacterial infection. Scabies and mite infestation are so itchy as to be distinct.

Topical antibiotics applied on skin breaks like cuts or breaks are useful in preventing infection. These ointments and creams are like “artificial skin”. Once again, prevention is key.

–Dr. C.

MEDICAL: ‘JOHNS HOPKINS MUSCULOSKELETAL CENTER’ – FOR MUSCLES, BONES AND CONNECTIVE TISSUES (VIDEO)

The Johns Hopkins Musculoskeletal Center aims to streamline and improve access for diagnosis and treatment of conditions affecting muscles, bones and connective tissues. Each of the center’s locations feature a diverse group of physicians, therapists, and advanced practitioners who work together to bring you the right treatment at the right time.

For more information

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #11: “SWALLOWING TROUBLE”

I am defining SWALLOWING TROUBLE as the difficulty in transport of food to the stomach, once clear of the throat. Problems with the initiation of the swallowing process are discussed separately.

PAIN in the mid-chest ON SWALLOWING is a worrisome symptom which can be due to inflammation of the lining of the esophagus from a variety of causes. An esophageal yeast infection, which can also involve the throat (called ‘“thrush”), often warns of immune deficiency and can be a sign of AIDS, or be caused by immune suppressing medication. If persistent, pain on swallowing can be a warning sign of CANCER.

If in the presence of GERD, it can be a sign of chronic inflammation or ulceration. In-coordination of the normally smooth muscular propulsive wave can cause a cramping, muscular pain.

Normal “peristalsis” is so efficient, that food can be swallowed without the help of gravity, when UPSIDE DOWN. I wouldn’t recommend trying this, even to cure hiccoughs. There is a muscular “gate” at the bottom of the esophagus, just as it enters the stomach. This gate is often too relaxed, and allows for the reflux of acid and food from the stomach, or GERD. It can also Fail to open, called achalasia, and hold up the food in its journey to the stomach.

The area can be scarred by repeated acid reflux, and become NARROWED; this is called a STRICTURE, and can cause a blockage in swallowing. One of my Doctor friends had to go to the Emergency room when some Steak got stuck in the esophagus.

The ER Doctor removed the steak with a fiberoptic Scope, and then proceeded to DILATE the stricture with a “bougie”, an instrument of a precisely calibrated size designed to STRETCH the constricted area. This uncomfortable procedure had to be done repeatedly, a caution to those who would wait too long before getting such a problem evaluated and corrected.

EOSINOPHILIC ESOPHAGITIS has been diagnosed with increasing frequency, and can cause Pain in the middle of the chest, trouble swallowing, and even regurgitation of food. This special type of inflammation is more common in allergic patients, and can be caused by certain foods.

So as you can see, swallowing trouble, if persistent, is nothing to fool around with, and should be checked out by a competent doctor. Don’t wait too long.

–Dr. C..

BLOOD VESSELS: THE “SYSTEMIC ARTERIAL SYSTEM”

BLOOD VESSELS; it is hard to overestimate their importance. They are literally our lifelines, delivering the oxygen and nutrition necessary for life. We are as old as our blood vessels.

I will divide blood vessels into 4 components with rather separate domains: The Systemic Arterial system, the Pulmonary circulation, the Venous system, and the Lymphatic system, and will discuss these separately.

SYSTEMIC ARTERIAL SYSTEM

The Boy Scouts taught me the pressure points; The radial, at the thumb-side of the wrist, the brachial, on the inside of the upper arm, and the inguinal in the groin area. Pressure on these sites will stop arterial bleeding distally.

You should be able to locate the radial artery pulse, and begin to appreciate its strength and regularity. Strength in case you encounter a person who isn’t moving, and regularity for yourself; many older people develop an irregularity called Atrial Fibrillation, and you might be the first to discover it..

ANEURISMS are swelling of the arteries, and the swelling may thin the arterial wall so that it can burst. A Cerebral aneurysm can burst and cause a stroke-like problem. If an aortic aneurism bursts, the internal blood loss can be fatal.

RAYNAUD’S Phenomenon is fairly common, and consists of an over-reaction to cold, where arteries of the hands constrict, and the fingers get white and cold. Burger’s disease involves small arteries, and often is associated with Raynaud’s. The arteries carry the blood distally (away from the heart), continuing to divide into ever smaller arterioles which terminate in capillaries, which branch out in such an arborization as to supply all cells except cartilage and parts of the eye.

HYPERTENSION develops when the arterioles, under hormonal or neural influence, constrict, increasing the resistance to blood flow, and so the pressure. Increase in sodium retention and therefore the blood volume can also increase pressure.

ATHEROSCLEROSIS is the common disease of western life style. Excessive calories and sedentary life style combined with genetic defects in fatty metabolism produce cholesterol plaques which narrow and stiffen the arteries, often leading to BLOCKAGE of blood flow. Blockage of flow to the HEART, BRAIN, KIDNEYS, BOWEL, or EXTREMITIES each produce their separate disorders of Myocardial Infarction, Stroke, Renal artery Disease. Intestinal ischemic syndrome, and Claudication.

Atherosclerosis

These disorders will each be separately discussed. I have always thought of vascular disease as a special class of CAUSATIVE MECHANISMS when trying to develop a DIFFERENTIAL DIAGNOSIS of a patient’s problems. Blockage to an area results in PAIN or LOSS OF FUNCTION.

Stroke is usually painless with blockage, since the brain has no pain sensors. Blockage of the renal artery often causes complex difficulties including Hypertension, because the kidney is an endocrine organ in addition to its excretory function.

A good Friend and patient showed what careful self-care can accomplish. It all started with a myocardial infarction, the first sign of his blood vessel disease. He had a complication in his workup, and had to have emergency bypass surgery. There had been damage to the heart muscle, with a large reduction in his EJECTION FRACTION.

His cardiologist gave him at most 5 years to live. That was 25 years ago, before the development of the statin drugs. He was given a draconian low cholesterol diet, which he followed exactly. One one visit to the cardiologist, he inquired whether he could have other areas of arterial blockage. His doctor then listened to his neck and discovered a bruit (noise) in the carotid artery, after which he had a Carotid endarterectomy.

In an orthopedist office for back pain, the orthopedist left the room, and my friend noticed in the CT scan report mention of cysts in the kidneys.

The Orthopedist cared mainly about his bones, and had overlooked the “incidental finding”. His brother had died of mesenteric artery blockage from atherosclerosis, he had stomach symptoms, and sure enough he also had arterial blockage to the intestines.

Bottom line: it pays to be an ACTIVE PARTICIPANT in our medical treatment, and even though we all have genetic determinants, we can make our health BETTER with attention to our health, especially SLEEP, DIET and EXERCISE.

–DR. C