Once Seen, Some Things Can’t Be Unseen

I wish I hadn’t seen that.

After the Boston bombing, the photos on the news of Jeff Bauman being wheeled urgently from the scene in a wheelchair while people attending him worked frantically to stabilize him were blurred from the waist down.  I figured his injuries were particularly gory, but then an unaltered photo made its way onto my Facebook news feed.

Tattered, blackened shreds of skin hanging like torn leather.

Bare splintered bone.

A man in a cowboy hat pinching his artery closed in his bare hands (which is probably the single most important reason why Mr. Bauman is still alive).

I’m a big girl, you know.  I’m over 40.  I made it through medical school and residency.  I’ve given birth more than once (which is more than a little gory and messy).  I’ve treated injuries, managed wounds and performed surgeries.

Still, there are sights I don’t need to see.  That was one of them.  And I am horrified for all the twelve-year-olds who have Facebook accounts and saw it too.  Luckily my ten-year-old is still not on Facebook, and recent events may push his electronic coming-of-age back a few more years yet!

However, among all the terrible images of the Boston bombing there were many good images.  The police officer who delivered milk on Friday to a family in Watertown with small children so they didn’t have to venture out on the streets.  The emergency workers and ordinary citizens with first-aid training who worked side-by-side to triage and stabilize the wounded.  The runners who finished running 26.2 miles then instead of celebrating went directly to local hospitals to donate blood.

I am reminded of the wisdom of Fred Rodgers, host of one of my favorite TV programs when I was a child, who has frequently been quoted lately.  “When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the helpers.  You will always find people who are helping.”  There were helpers galore in Boston that terrifying week.  From small things to true heroism, the helpers are the ones who put Boston back on its feet and gave the frightened a reason to feel hopeful.

I’d like to salute one of the most amazing heroes of this newest chapter in America’s war on terrorism:  Jeff Bauman himself.  After being stabilized and going through surgery to finish the job the bomb started, he woke up and insisted on talking to the police.  After suffering amputation of both his legs, his first instinct was to help identify the bombers responsible for his injuries and those of the others hurt and killed.  Who knows how many lives he saved by identifying them so quickly?

These are the lessons and the images I’d like the world to see, so they mark and remember the resilience of Americans and our refusal to be afraid just because two madmen chose to bring violence to innocents on Patriot Day in one of the proudest American cities.  These are the images I want to remember and the images I will share with my sons.

God bless America!

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What Does Anemia Mean?

I seem to be having a theme in the last few weeks!  I’ve been seeing lots of people with blood problems and the most common blood problem is anemia.  WebMD estimates 3.5 million Americans have anemia.  So what’s anemia?

Anemia is a condition where there are less than the normal number of red blood cells in the bloodstream.  Red blood cells function to carry oxygen from the lungs to the tissues where it is used.  Every single cell in your body uses oxygen and they can’t go very long without it.

If you are anemic, either you are losing red blood cells too quickly or you are not making enough to replace the red blood cells that are being lost (or both).  The “red cell mass” (total number of red blood cells in the circulation)  is a balance between new red blood cells being made and old red blood cells being destroyed.  The spleen takes damaged red cells out of circulation and a red blood cell usually has a useful lifetime of 2-3 months.

There are conditions that can increase the rate of loss of red blood cells, including some inherited conditions, infections and medications.  There is also a problem called hemolytic anemia, where the red blood cells break open and release the hemoglobin (the pigment that colors the blood red and actually carries the oxygen).  However, far and away the most common reason to be losing red cells faster than they are replaced is by bleeding.

When I say bleeding most people think of the bleeding that happens when you cut your finger.  That is not nearly enough to make you anemic.  Bleeding significant enough to cause anemia is usually heavy menstrual bleeding over a long period of time, bleeding in the stomach or intestines which can be either fast or slow, or blood loss from major trauma or surgery.

Red blood cells (like all other blood cells) are made in the bone marrow.  There is a hormone made by the kidney called erythropoietin which tells the bone marrow to make more red blood cells.  Kidney problems can decrease erythropoietin levels and lead to anemia.  Also, the bone marrow needs lots of building blocks to generate hemoglobin and red blood cells.  The most important ones are iron, protein, vitamin B12, and folic acid.  Deficiencies of any of these building blocks can lead to anemia.

The first step to treating anemia is to discover the cause.  If it is a deficiency, you replace the building block that is missing.  If it is due to kidney disease there are injectable medications to replace the activity of erythropoietin and stimulate the bone marrow to make red blood cells.  Obviously if there is bleeding we need to find the source and stop the bleeding (ulcers, colon polyps, heavy menstrual periods, etc).

If you think you might be anemic, or you know you’re anemic but don’t know why, please see your doctor.  A simple blood test can make the diagnosis and start the process of finding and fixing the cause.

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Deliriously… Well, Delirious

This is seriously important information for anybody with an elderly family member.

I just atttended a geriatric medicine conference in Pittsburgh this weekend.  Geriatric medicine addresses the particular needs of elderly patients.  We had a variety of very good and informative talks, a couple of boring and unhelpful ones, and a few that were rock-your-world-OMG-I-had-no-idea good.

One of the ones that I know will change the way I practice medicine discussed delirium in hospitalized patients.  There are a few pearls that I particularly want all of my readers to bear in mind the next time you have an elderly family member in the hospital.  They deal with delirium in the hospitalized patient.

First of all let’s define delirium.  Delirium is an acute confusional state.  Basically either a normally coherent patient becomes confused and incoherent, or a patient who is confused at baseline becomes acutely worse.  Generally it also involves a change in level of consciousness as well (either drowsy or agitated) and the inability to focus on tasks like answering questions.  Patients may hallucinate (see or hear things no one else can see or hear).  It is very common:  estimates are that 14-24 percent of all hospitalized elderly patients and at least 70% of elderly patients sick enough to need to be in ICU become delirious.

What are the causes of delirium?  You name it, it’s on the list.  Infection, drugs, cardiovascular problems, pain, low oxygen levels, sleep deprivation, being out of their normal environment, the list goes on.  Usually it’s not just one cause but a combination of multiple triggers.

My big epiphany was learning that delirium in the hospital has long-term consequences.  There was a nice study published about heart-surgery patients, which showed that patients who get delirious after surgery have cognitive dysfunction (i.e. confusion and problems with memory and thought) that persist for up to a year after their surgery.  The longer the delirium lasts, the longer the cognitive dysfunction lasts.

In medicine we all sort of accept that elderly patients are going to get confused in the hospital.  I frequently tell patients’ families that “this happens, s/he will come out of it, and we’ll just keep him/her safe until it corrects itself.”  Now I think I’m going to be a lot less accepting and more aggressive about evaluating, identifying and treating the causes of acute confusion in elderly hospitalized patients!

So where do you come in?  Well we don’t always have an easy time recognizing acute confusion.  If a patient of Dr. Matt’s comes into the hospital and I’ve never met her before, how am I going to know she’s not typically confused?  It’s even harder to tell when the patient has baseline dementia or is forgetful normally.   Delirium also typically waxes and wanes, so if I see her first thing in the morning, and she gets confused in the evening, I may not know about it unless an astute nurse (or family member) calls to tell me.

Here’s your job:  if your parent or grandparent or other elderly family member is in the hospital FOR ANY REASON, organize family members to visit at various times of the day to check on them.  Pick people who know the patient well and can spot changes in their mental state.  Have them on the lookout for ANYTHING unusual and speak up to the nurse or call the doctor if something goes left-of-center.  Remember, we can only treat something if it’s recognized!

We want our elderly patients to be as functional and independent as they possibly can be.  We can’t always anticipate and head off confusion in the hospital, but the sooner it’s recognized and addressed, the sooner the patient will be back to normal mentally.  It turns out fixing delirium in the hospital is very important for long-term mental function and keeping people independent and out of the nursing home.

I frequently say patients (especially elderly patients) can’t be treated in a vacuum, we have to take their families into consideration.  Sometimes honestly families are more difficult to manage than the patient!  This is one instance (one of many, actually) where rallying the troops can help keep your family member safer and get them well faster.

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