Monthly Archives: March 2016

Exercise Hating

While I was on vacation, one morning I woke up and I was scrolling through Facebook (as many of us do). I saw that some girl I went to high school with was mentioned in the comment of an article about how CrossFit is basically the devil and worst thing ever created.  As someone who has been crossfitting since before the reebok endorsement I’ve listened to my fair share of “Crossfit Hate”.

Don’t be fooled, this is not an article in defense of Crossfit; (I refuse to go there) however, a statement in support of health, wellness and fitness.  Everyone is entitled to their opinion and to choose whatever fitness regimen/program that works for them.  Before I was a PA, I was a personal trainer and I’ve always supported the idea that you cannot force someone into fitness if it is something they despise.  Everyone needs to find something that is enjoyable for them. If you don’t enjoy it, you won’t sustain it.  By nature we are not creatures who do things that we outright hate and make us miserable.  (I’m not talking about subliminal crap like abuse and why we pick our spouses–talk for another day and website).   Fitness, health and wellness is absolutely no different.

Instead of absolutely bashing each other for what we choose to do for exercise, here is a crazy idea: why don’t we support each other?  I know, its novel–but perhaps more of us might think about giving it a try.  There are a lot of fitness regimens and types of exercise out there I despise.  I’m no yogi (although I go once in a while to get my flex and Namaste on) and if I tried to golf I’m certain I would wrap a club around a tree with frustration–I’m clearly meant to lift heavy weight for time with that mentality.  I used to run–a lot and hate it now.  But I love CrossFit and swimming (ok and the occasional run). I know a lot of people who have discovered healthy lifestyles through Pure Barre, Yoga, running, biking, triathlon’s, etc. Who am I to tell them what they do is stupid?  Um, no one.  In fact, it makes me ecstatic that more people are finding methodologies that lead them to a healthier lifestyle.  I recently read Amy Poehler’s “Yes Please” and she said something amazing.  We all spend a lot of time critiquing others and she decided that her motto would be “Good for her, not for me”.  Rock on girlfriend, I couldn’t agree more.  Just because it isn’t for you doesn’t mean it doesn’t influence a ton of people in a positive manner.

Yes, Crossfit can be dangerous.  So can every other sportAlso, 712 people died from accidents with hammers last year, so apparently hammers are dangerous as well. There are bad apples in every bag and not everyone who coaches or participates in Crossfit is safe.  My point is this to the girl who wrote that article and anyone else who hates on whatever form of fitness others choose to engage in: Support others and whatever makes them happy and healthier.

Remember: “Good for her, not for me”.  (this saying can also apply to men by changing the gender 🙂 )

Medical Musing of the Week: Rhabdomyolysis 

Overview

  • Literally means “Disollution of Skeletal muscle”.
  •  The injury to skeletal muscle causing toxic intracellular contents such as myoglobin to leak into plasma

Pathophysiology

  • Inciting injury is of skeletal muscle somehow, how the muscle becomes injured is what’s variable. After the muscle becomes injured myoglobin is released in quantities damaging to the kidney resulting in ischemia and tubular vasoconstriction.  This process results in AKI w/ disturbance in myocardial and calcium hemostasis.
  • Release of intracellular myocyte components
  • Depletion of ATP
  • Increase in proteases, proteolytic enzymes and free O2 radicals-> leading to leakage of potassium, phosphate CK, and myoglobin

image

 

Etiology

  • Crush Injury
  • Snake venom
  • Orthopedic trauma (be sure to r/o compartment syndrome
  • Immobilization and hypovolemia
  • Infection (Most common infectious cause are Influenza A&B)
  • Genetic muscle defects (those which cause a ATP supply and demand mismatch)
  • Hyperthermia
  • Low phosphorus and potassium
  • Propofol is the most common drug that will cause Rhabdomyolysis in children
  • Exertional Activity aka working out too hard (sickle cell patients are at increased risk of rhabdo d/t exercise

Clinical Manifestations

  • Classic Triad (presents less frequently in children) Tea colored urine, myalgia and generalized fatigue
  • History: to determine cause meds/trauma/infection/ETOH/drugs.  Individuals who have started new exercise program.  Esp if they were prior athletes (increased risk)
  • PE: edema (esp if unilateral)
  • Decreased strength
  • Skin changes consistent with necrosis
  • Hyper/hypothermia
  • MC muscle group injured in adults are calves and lower back

Diagnosis

  • CK levels are the most reliable/check q6-q12h/rise within 12 hours/peak 24-36/should decrease approximately 30% per day with treatment
  • Myoglobin: if negative does not rule out, can have false negative because will clear system in 6 hours/ if positive he atria can get myoglobin urine assay
  • EKG to look for changes due to electrolyte abnormalities
  • UA is WNL in >50% of patients and therefore is not a reliable measure

Treatment

  • ABCs
  • IVF resuscitation–aggressive as long as EF is intact 2-3L bolus and maintain at 100-200cc/hr
  • Activity restriction-no aggressive exercise
  • Electrolyte replacement as needed (keep mag >2.0 and K >4.0–cardiac

Complications

  • Compartment Syndrome
  • Decreased albumin
  • Hyperurecemia
  • DIC

Due Diligence For All PA’s

When I wrote my essay for PA school I talked about wanting to represent the profession with the highest possible standards.  I meant a few things by this. First the whole do no harm thing. Even though we don’t take an oath as Physicians do, I still believe we have the responsibility to act under this concept.  I also meant that I wanted to portray the profession as best as possible to each of my patients.  As PA’s I believe that we fight a somewhat uphill battle in gaining the respect we deserve from patients because we “aren’t doctors”–which we are not that is true.  However, we are medical providers and I want to advocate for that with every patient I see. By taking time with each patient, being through and explaining whatever is going on with a that specific individual.

I believe that each of us has the basic responsibility to leave each patient thinking and feeling that they saw a competent, intelligent provider who was able to address all of their issues and questions.

As PA’s I feel as though I will always have a sense of ” I need to prove that I’m capable enough to do this job”.  I’m not sure if that feeling resonates with Physicians or not; but as PA’s we are in between levels of care.  Either a lot is expected of us or nothing sometimes. That being said, I am doing my due diligence to educate myself and gain the most knowledge possible to be the best possible provider I can.  I’m treating my first three years of working experience as if I was a resident.  Constantly learning and betting my practice.  Not to say that I will not do that after three years is up–mecidcine involves constant learning as part of the responsibility of our career.

To the new PAs out there (and even those who have been practicing some time) do you part and with each patient seek for them to have a great experience with your care.  Not only is it good for patient care, it’s also further steps in the right direction for our profession.

Medical Musing of the Week: Hepatopulmonary Syndrome

Overview

  • Hypoxia in setting of patient with kown liver disease and likely Pulmonary HTN
  • Less common complication of Cirrhosis/ESLD (est 4-47%)
  • Triad:
    • Increased Arterial to alverolar O2 gradient
    • Pulmonary Vascular Vasodilation
    • Underlying Liver Disease

Pathophysiology

  • Type 1: Increasesd circulating vasodilators such as nitrous oxide, leading to vasodilation in capillary and precapillary beds of the lungs
  • Type 2: AVM’s
  • Overall patients have an increased in total number of dilated vessels

image

Clinical Manifestations

  • Platynea: Dyspnea when sitting up and relieved lying down
  • Orthodeoxia: Decreased arterial O2 tension (>4mmHg) or arterial oxyhemoglobin desaturation of >5% from lying to upright
  • Hypoxemia (not specific)
  • Liver disease present
  • Digital Clubbing
image
Digital Clubbing.

Diagnosis

  • O2 Therapy will temporarily improve patients with type 1 but not type 2 (because it is an AVM)
  • Contrast enhanced echocardiogram is preferred study for diagnosis–> contrast injected if normal will only opacify right chambers of the heart because they will be filtered by pulmonary capillary bed.
  • Intracardiac shunt is demonstrated if contrast is visualized in L heart within 3 beats.  Intrapulmonary shut (as in hepatopulmonary syndrome) will occur slightly later after 3 beats and usually within 3-6 beats
  • TEE is a better study but also more invasive and is contraindicated in patients with varices
image
God love radiologists. I can’t appreciate anything besides the right lung looks substantially different than the left. God speed to those who can 🙂

Treatment

  • Type 1 patients can be offered improvement of symptoms with oxygen.
  • Type 2 patients will require embolization  as O2 therapy does not offer any relief in the setting ov AVM’s
  • Definitive treatment for both is Liver transplant.
Resources:
UpToDate & Principles of Critical Care (Sonali Sakaria & Ram M. Subramanian)