Here's the EKG again:

What do we see?  Flipped T-waves in the anterior and lateral leads, poor, even odd R wave progression, short possibly even absent PR intervals and bradycardia.  It's kind of ugly.  One would expect the patient to be experiencing some sort of symptom of cardiac compromise.  Nada, nothing.

Here's the presentation: 28 year old, 6 months post-partum, comes in with progressive left-sided weakness. Had been seen at the PCP earlier in the weak and given scripts for muscle relaxants and steroids on the idea this was a muscloskeletal issue.  Patient decided to come to the ER after dropping her child due to the weakness (the kiddo was fine).  The above EKG was shot prior to her going to CT for a head CT, followed by another imaging modality: MRI.  Both show a bilateral ischemic event, right greater than left, mostly in the frontal and prefontal area with some scattered subcortical spots as well.  Big time, acute ischemic CVA.

So what's up with this EKG?  Neurogenic T wave inversion.  I found several articles on Ovid about this phenomenon.  According to one article, 74% of patients with cerebrovascular incidents exhibit alterations in cardiac depolarisation and repolarisation.  Most commonly these cardiac alterations are in things like prolonged QT intervals, T wave inversion, ST segment changes and abnormal U waves.  This possibly is caused by unbalanced autonomic control due to the location of the ischemic events.  The most common culprit is the insular cortex located within the lateral sulcus, overlaid in some parts but the frontal lobe - where the were several ares of ischemia.  Now I can't say for sure that this area was damaged, and judging by the literature, usually the alterations are more defined and substantial.

Now here is where it gets really interesting. Why would a 28 year old have an ischemic CVA.  No history of hypertension, no cardiac history to note, normal birth, but an aunt who had a similar event at the same age.  Carotid and cerebral angiography was performed giving the diagnosis of moyamoya disease.  Simply put, moyamoya is a progressive occlusive disease that causes stenosis of the carotids and the Circle of Willis.  Leading to occlusion of the vessels.  A large collateral network does form and sometimes retrograde filling of the cerebral arteries is seen as well.  True diagnosis is through angiography where there is a "puff of smoke" appearance to the cerebral vasculature.  Most folks don't even know they have it until they have an event of some variety.  Much of the time it is a TIA type, but sometimes it comes as a large cerebrovascular event.  Moyamoya is also a leading case of stroke in children, even very young kiddos.  The consensus is that it is genetic and considering that the patient's aunt suffered a similar event, coincidence aside, that looks pretty solid.

So what happened?  Since we are a nationally recognized stroke center, the patient admitted under our stroke protocol.  Through the first night and later on they would have alterations in their rhythms, running junctional rhythms, SVT and sinus tach along with normal sinus rhythm.  The biggest deficits was to the left arm with some mild to moderate in the left leg.  She didn't experience any expansion of the ischemic areas during her time on our floor and was relatively stable.  Prior to heading to a rehab floor, referrals were given for surgical consultation through Stanford for a surgical solution to her disease.

I think this was a case of the long-tail of medicine.  Happy had a post about this and it sparked this post as well.  We get so used to seeing this kind of EKG in a totally different light that a new perspective sometimes throws us way out of whack.  I showed the EKG to a fellow EKG nerd and the first thing he asked was, "Did you call the doc over this?'  I explained the situation and the lights went on.  I had no clue about moyamoya prior to this, so it was a huge learning experience for me.  Fascinating and a little bit sad as well.

There you have it.  Hope you enjoyed this round of EKG of the month.  Hopefully next month there will be a crazy cardiac one...well maybe not, that would mean bad things might be happening.

First, a brief  synopsis.

Deborah Peel, a 28 year-old, 6-month post-partum patient arrives at the ED complaining of weakness.  This EKG is grabbed on admit.

To give much more information (including what kind of weakness it was) would give this away.  Suffice to say, labs were normal, including cardiac enzymes.  Vitals signs were stable, blood pressure was slightly elevated though.  Patient was complaining of no chest pain or other symptoms that would be expected with the tracing shown above.  No previous history, normal delivery without complications 6 months prior.  The other clue I will lay out is that the patient went for a CT, followed by another imaging modality before arriving on my floor.

Any guesses?  C'mon, fame and glory await!  Leave your guesses in the comments.

P.S.  I have to work the next couple of days,but I'll be checking to see and will confirm or deny guesses,also in the comments.  I will also say that my firend who looked at this said, "Did you call the doc? How about an EKG when they got to the floor?"  Both of which were answered in the negative.  Is your brain in gear?

Gegen Trübsinn schrieb Paul Gerhard dieses Lied seiner Verlobten Anna Maria Berthold. Paul Gerhard setzte alles daran, die aufgrund der Erfahrungen durch den Dreißigjährigen Krieg sowie der von Pest, Pocken und Ruhr geplagten Stadt Berlin betrübte Geliebte wieder aufzubauen. Er verfaßte ein Gedicht, das in 15 Strophen die Schönheiten der Schöpfung vor Augen hielt und sie zu einer Tätigkeit aufforderte, der sich höchstens ein adeliges Fräulein hingab, die für ihren Stand höchst ungewöhnlich war:

"Geh aus mein Herz und suche Freud
In dieser schönen Sommerzeit
An deines Gottes Gaben
Schau an der schönen Gärtenzier
Und siehe wie sie mir und dir
Sich ausgeschmücket haben"

Wellness für die Seele - es geht immer weiter, das Leben, das zeigt mir die Gemeinschaft im Seniorenkreis immer wieder und die wertvollen Erfahrungen, die wir da austauschen können. Egal, wie das Leben einem mitspielt - es geht weiter. Also: Sorge unterdessen immer mal wieder für ein bißchen Wellness für deine Seele.

Das Lied mit seinen 15 Strophen zu lesen, kann eine mögliche Methode dazu sein - Kaffee und Kuchen eine andere! Noch ein Beispiel, mit dem es dann auch genug sein soll: :-)

"Erwähle mich zum Paradeis,
Und laß mich bis zur letzten Reis
An Leib und Seele grünen;
So will ich Dir und Deiner Ehr
Allein und sonstern Keinem mehr
Hier und dort ewig dienen"

By STEPHANIE NANO

The Associated Press

NEW YORK

Heart exam, EKG recommended before children receive stimulants for attention-deficit disorder

Children should be screened for heart problems with an electrocardiogram before getting drugs like Ritalin to treat hyperactivity and attention-deficit disorder, the American Heart Association recommended Monday.

Stimulant drugs can increase blood pressure and heart rate. For most children, that isn't a problem. But in those with heart conditions, it could make them more vulnerable to sudden cardiac arrest — an erratic heartbeat that causes the heart to stop pumping blood through the body — and other heart problems.

About 2.5 million American children and 1.5 million adults take medication for attention-deficit hyperactivity disorder, or ADHD, according to government estimates. Stimulant drugs, like Ritalin, Adderall and Concerta, help children with ADHD stay focused and control their behavior.

The medications already carry warnings of possible heart risks in those with heart defects or other heart problems, which some critics said were driven more by concerns of overuse of the drugs than their safety.

The heart group is now recommending a thorough exam, including a family history and an EKG, before children are put on the drugs to make sure that they don't have any undiagnosed heart issues.

"We don't want to keep children who have this from being treated. We want to do it as safely as possible," said Dr. Victoria Vetter, a pediatric cardiologist at the University of Pennsylvania School of Medicine and head of the committee making the recommendation.

The label warnings were added after a review by the Food and Drug Administration of its databases found reports of 19 sudden deaths in children treated with ADHD drugs and 26 reports of other problems including strokes and fast heart rates between 1999 and 2003. There were also reports of heart problems in adults; the committee didn't look at adults.

An EKG can detect abnormal heart rhythms that can lead to sudden cardiac arrest. Children who are already on ADHD drugs should also be tested, Vetter said. If problems are found, the child should be sent to a pediatric cardiologist. With careful monitoring, Vetter said, children with heart problems can take the medicines if needed.

The cost of an EKG varies depending on who does it and the location. For example, the amount that Aetna Inc. pays for an EKG in a doctor's office ranges from $24 to $50; Medicare's payment rate is about $23. Vetter said Children's Hospital of Philadelphia, where she works, has been doing EKG screening for three years and it has been covered by insurance.

She said a screening of about 1,100 healthy children found that about 2 percent of them had some kind of heart problem.

"We thought it was reasonable to include the electrocardiogram as a tool for the pediatrician, the psychiatrist so that this would help identify additional children who have heart disease," Vetter said.

But Dr. Steven Pliszka, a child psychiatrist at the University of Texas in San Antonio, said he was baffled by the EKG recommendation. He said there's no evidence that sudden death is a bigger problem for children taking stimulants than for children who aren't taking the drugs.

Pliszka said an EKG might deter people from seeking treatment because it's an added expense and hassle. Psychiatrists aren't likely to have an EKG machine, and pediatricians might not either, making patients go elsewhere to get the test, he said.

The American Academy of Child and Adolescent Psychiatry recently updated its treatment guidelines for ADHD, and did not recommend routine EKGs, said Pliszka, who was the lead author. He has received research support or served as a consultant for makers of ADHD drugs.

"We definitely did not feel we needed to screen everyone," Pliszka said.

He noted that the heart association doesn't recommended EKG screening for young athletes to prevent sudden death. The group has said it wasn't feasible or cost-effective to screen all student athletes.

Representatives for Shire PLC, which makes Adderall and two other ADHD treatments, and Norvartis Pharmaceuticals Corp., which makes Ritalin, said the labeling already suggests patients be evaluated for heart problems and an EKG done if needed.

"There's no new information here. And frankly, we're a little perplexed as to the purpose of the American Heart Assocation coming out with this statement at this time," said Shire spokesman Matt Cabrey.

An ADHD advocacy group called CHADD said parents should monitor their child's reaction to all medications. EKG screening "will bring an even further measure of safety to what is already a safe clinical treatment approach," the group said.

midőn sörrel a kezében leül egy kőre
"szem-szája ingerem de
elmenteni? dőre..."

My heart was alright and I was able to do my Herceptin treatment on Thursday, just 2 days late.  I am glad I was able to continue.  I still have to go in next week and do a heart stress test (treadmill), just to make sure, and then we can rule out heart disease, and see if we can find out what is really wrong.

I think it is because there has been so much pain in my life in the last 9, 10 months dealing with cancer, that the pain is trying to find its way out of my body right now and unfortunately my big heart is how the pain has decided to discharge itself.

My heart pains stressed me a bit, but what was MOSTLY stressing me out, was going to another doctor, having an EKG, then going back to my Oncologist, then being called again by the internal medicine doctor to come back, blah, blah, blah.  I is tired of doctors, and I just want to be done now because I am ready to move on, get well, regain my energy, and not see another doctor unless it is for check up, yup, yup, that's what would make my heart happy!

Harga  :  Rp. 11,400,000

o] EKG Merk Fukuda ME Type C120

Harga  :  Rp. 18,500,000

Hollywood - ever scavenging for dramatic and at least obliquely true material - loves the precordial thump. The "thump" is basically a whomp on the chest when someone has had a heart attack. How cool. How many times in your life can you physically assault someone and then be regaled as a hero for it later? Kinda the Dr. Jekyll + Mr. Hyde amalgam of the medical world. Melt evil and goodness into one fantastic smashing fist on a dead man's chest and viola...you saved a life.

Of course, you could just get sued for it. Or maybe prosecuted. The next time you're in a bar fight, you might try the Precordial Thump defense (the bastard half-cousin of the Temporary Insanity defense). "Yeah, so I hit 'im. So what? I thought he was dyin'. I was giving the jerk a precordial thump."

"But he's missing teeth."

"Well, I aimed too high."

Anyway, probably the thing that movies and T.V. most often get wrong is that CPR - especially with The Thump - pretty much never works. If it DOES work, it needs to have been successful reallyreallyreallyreally soon after the patient collapsed. Some people say 10 minutes. I think it's actually more like 4. They may come around after 4 minutes, but they will have permanent brain damage of varying severity.

I've recently found myself sucked into the "Lost" T.V. show vortex (thanks to my wife, an ardent fan). I'm still working my way through the first season, which involves a bunch of people who are planwrecked on a South Pacific Island. Most annoying about the show is that there are in fact really crummy waves, which makes no sense to me, since I constantly dream of head-high barrels surrounding every S. Pac Island (all 10,000 of them) at all times. They might as well show me some great waves.

Anyway, there's a doctor among the castaways and he helps out the sick people whenever he can. Often the medicine is realistic and/or simplistic enough to be enjoyable. But at one point he found one of his fellow castaways in a tree - hung by a bad guy. It took a few minutes just for the doc and his super-model gorgeous sidekick with eternally perfect makeup hair and lighting despite the remote island locale...to cut him down. Then the doc proceeds to pound this guy on the chest repeatedly for A LONG TIME. And (I shouldn't be spoiling anything here since Season 1 was 4 years ago), he saved the guy. No brain damage. Talking by the end of the show.

Not realistic. For many reasons. Works for Hollywood, though. Bugged me, of course.

So here's the deal. Thumps can be used when the heart needs electricity, which isn't all the time. The most common type of heart rhythm that needs electricity is ventricular fibrillation, when the ventricles are trying to pump, but doing a bad job of it. They're basically quivering. But they're responding to electricity and doing what they can to get blood out into the body. The most likely heart rhythm after prolonged asphyxiation is going to be asystole. No heart beat at all. Dead. Flatline. You could plug that heart into a city power plant and it wouldn't help.

Precordial thumps generate about 20 Joules of energy. It isn't much more than the static zap you get from walking around a Sasquatch rug in your socks. By contrast, we give at least 200J of energy in defibrillation shocks. These days, we usually give even more than that. So the only time you can really hope for the thump to work is immediately following the heart attack. At that point, the heart may only need just need a little jump-start. The blood isn't acidic yet, and everything is still kinda holding together. Even a few minutes later and El Thumpo will be nothing more than a weak legal defense to get out of a bar fight.

A more useful time to have used the thump may have been with the recent heart attack and death of Tim Russert, the journalist icon who collapsed in the sound studio while at work. His co-workers did everything they should have, including starting CPR and calling 911. And the paramedics tried real defibrillation unsuccessfully. But a thump may have helped because Russert's collapse was witnessed, which means the small 20J jolt would have arrived almost immediately after his heart rhythm had switched. Also, the myocardium (heart muscle) usually goes into ventricular fibrillation first, then progresses to asystole a bit later. Russert was in Vfib when the paramedics arrived.

The thump probably won't help anyone ever. In a thousand thumps, probably about 1/3 of a human actually benefitted from it. It's more theory than realism and isn't even taught in CPR or advanced CPR classes. But if you see someone drop, they have an open airway and they have no pulse...punching them in the chest might be justified. It probably won't help, of course, and might get you sued or thrown in jail.

That said, if someone happens to film your medical heroics, you could always send the tape out to Southern California. Who knows...you might end up on T.V.

Und direkt daneben, nur einen Klick entfernt auf Youtube dieses Video. Bestimmt schonmal gesehen, aber immer noch spitze. Sie wird ja schließlich nur fürs Aussehen bezahlt. Und das tut sie, soweit ich das beurteilen kann, ziemlich gut.

OK UPDATE:

Tuesday - I believe I blogged already about my horrible day of syncope and near syncope experiences and the moron doctor. After running the EKG and reviewing the holter moniter he concludes that it's not my heart but my brain doing this - more specifically likely dysautonomia or seizures or something to that affect. In all honesty, I think this case is so out of his ballpark it scares the crap out of him and he was just trying to get me out of his office.

Wednesday - I got to work because he never said I couldn't. Yeah, people object when I get there. "You shouldn't be driving around until you know if you're not going to black out!" Well, duh, but what choice do I have? Now really? I know for a fact they won't call in a sub last minute. They just won't. But all is well, for the most part. I do have a tiny moment while sitting on the gym floor. My heart begins to race and so I excuse myself to the bathroom and get drink of ice water from the fountain. I sit down and take some deep breath and just close my eyes. It's very cold in the hall way and thankfully, it passes quickly. I still feel a little strange, but never get worse. Later that night I'm sitting on the couch watching Dan in Real Life - a funny, lighthearted romantic comedy movie. The kids are over to their aunts. The house is quiet. My husbands on the computer. And I'm watching the movie, enjoying it and relaxing when all of a sudden my heart starts racing very fast, and I feel like I'm being pulled down. It takes about ten minutes to pass and I feel like I could literally white out twice during the whole episode but don't. My husband makes me finish the movie from our bed, since lying down seems to be the only thing that helps.

Thursday - A few episodes where my heart started racing or I felt a little light headed but that was it.

My husband e-mailed me yesterday and asked me if I was having a good day. I replied to him: "Yes. I haven't passed out!" He replies that normally someone wouldn't answer that question like that, but seeing as it's coming from me, that's a very appropriate answer. Given the week I've had, if I can say I haven't passed out, then that is good.

I have just returned from the hospital. I was discharged with a clean bill of health. My EKG was "perfect" as the doctor said, my blood pressure was 131/75 and my blood sugar was 89. Great, I'm not having a heartattack and I am not diabetic (this was an initial concern dude to the fact that my dad is dabetic and I was incredibly thirsty upon arrival to the ER) So, since I am in good health, what brought me there?

Well, I went to bed early to try and get back on a normal sleep schedule because staying up until 4am and not waking up until noon or later was getting ridiculous and I need to do something with my life. So, I hit the hay after 10 and off to dreamland I go.

Fast forward to about 12:20am and I woke up..I figured it was because my body was just not ready to sleep...so on to facebook I go and I just felt completely disoriented...I thought it was because I woke up and hadn't adjusted to it yet. Back to bed I go. I was determined to get a good night sleep.

Laying in bed, my disorientation just doesn't go away. I knew something was wrong...I could feel that I was just starting to get anxious...and if last time this happened was any indication, my heart would began to start racing momentarily. I decided to walk upstairs, use the bathroom and I would be good.

I am just about to the bathroom and instead I go in to tell my mom..because she is a mom and she will fix it (I may very well be 22 years old, but my mom can still fix it all). I wake her up out of what I am sure was a deep sleep and tell her my heart is racing. She gets up, wakes my dad and tells him we need to go to the ER. My dad is curious as to what is going on, my mom feels my heart and says that it is indeed racing and we should probably go. I go to change and am ready to go, because at this point, I just want to not feel like I am...I don't know how to describe it, I don't feel sick it is almost like an anxious feeling. I grab a water and head out the door. That water was gone in seconds..and suddenly my mouth is incredibly dry and I can't get enough to drink.

We arrive at the ER, I tell the lady my heart is racing they take me into room, it isn't an exam room, it's the room before that, they ask you questions about your health, how tall you are, weight..things like that. The guy took my pulse (it was 126..in case you aren't aware...this is definitely NOT normal). The doctor comes into the room and says we need to move to and exam room (room #2 if you are wondering) because an ambulance was on its way in.

I am in the room, and that damn glass of water cannot stay full enough. They continue the questions to try and figure out what my issue is. In comes Deb, a very nice lady, to hook me up to an EKG machine. Now..if you have been lucky enough to NEVER have had to get hooked up to one of these machines...you aren't missing out. They take these..'conductors' and stick them..ALL over you..one one each ankle..5 around your heart..and a few others spread across your chest. and then they have to take these cords and hook them to they sticky things to get a reading. It isn't painful at all..there is just a lot of wires and it is incredibly annoying.

Anyways, back to the story...they get my EKG print out and Deb takes it to the doctor (Dr. Kim). He comes back in and he said that it was, and I quote "perfect."

Dr. Kim then sat down and started asking my questions about my life and am I happy and have I been having racing thoughts..or thoughts of suicide (I have not) and I answer him. And I tell him I am just stressed about not having a job..yadda..whatever. Dr. Kim says, he just thinks that I am stressed with everything and he was going to get me some Valium so that I could relax, but also take my blood sugar because I am so thirsty and he wants to make sure I am not diabetic.

Deb comes back in with the testing thing that you use to test your blood sugar. She takes mine, it is 89..this is apparently really good. Dr. Kim comes back in and asks if I am feeling better..I am (hell if you give ANYONE 2 Valium..you better believe they are gonna be feeling better). He gives me and my mom a printout to read about anxiety...guess what one of the symptoms is...dry mouth!

Turns out, I suffered from what I would consider a mild/sever anxiety attack. He writes me a prescription for Valium for me to take AS needed if this situation were to arise again. By this time..the Valium..hits me and I just want to sleeeeeeep.

After all was said and done, all is well. I am relaxed...calm and tired. I am thankful that I am healthy. On a final note, I would like to address the ER:

Dear ER,

You and I have got to stop meeting like this. It seems that it always ends with my hooked up to and EKG machine fearing for my life.

Thank you for your cooperation.

[sC]

***Caution! Educational Material Ahead!***

Click here to avoid said educational content.

OK, that out of the way, here goes...

Junctional Ryhthms

Usually an escape rhythm initiated by the junction (hence junctional...) at the AV node, a back-up if you will for when the normal conduction of the heart is altered. In the strip below, the patient had undergone an EPS and targeted ablation for recurrent atrial fibrillation. They had been throwing everything thing from junctional escape beats, straight junctional, accelerated junctional, junctional tachycardia, idioventricular beats and ventricular pacing. To define:

Junctional Escape Beat: 1-2 beats, originated in the AV node, rate is 40-60 bpm.
Junctional Escape: 3 or mores beats, in other words, continuous junctional beats, again rate of 40-60 bpm.
Accelerated Junctional: 60-100 bpm, where the AV junction has taken over as the primary pacemaker.
Junctional Tachycardia: >100bpm, again where the junction is the primary pacemaker.
Premature Junctional Beats: same as escape beats, but earlier than expected. QRS morphology is usually different as well, like a PVC.

How to spot:
Usually has "normal" QRS structure with either a PR interval <0.12s, a missing P wave (buried in the QRS) or a retrograde P wave appearing after the QRS.

What it means: something ain't right, as in, "that boy ain't right."  Something is causing the conduction system to be slightly out of whack, or if you're a carpenter, half a bubble off. In his case, they had probably caused some collateral damage in the process of targeting his aberrant foci during his ablation, in fact, when asked if he wanted to do anything, the doc pretty much said he was expecting some weirdness from this patient and just to watch him. This can also be caused by drug (dig anyone?) toxicity, 'lyte imbalances, ischemia, even trauma - we see a lot of rhythm disturbances on our folks post-valve surgery.

So here it is:

We're looking a accelerated junctional, maybe junctional tach. Notice the 5th and 12th beats look a little different, both I and the tech were calling these PJCs, although they may be PVCs. Also notice the retrograde P-waves popping up after the QRS. The other strip, which I left at work showed the true anarchy of the patent's rhythm. This looks good comparatively. Hemodynamically, he was stable, just every 10 minutes or so, the tech would come up to the nurse with a new strip to show how his rhythm kept changing. She just kept looking at him like, "uhh, OK, I'm looking at what now?" Like I said, we don't see this all that much. He was supposed to go back to the lab for a 3rd ablation, but the general consensus among us was that they needed to adjust his pacer and wipe out the node completely, but hey, we're just nurses, right?

Pacemaker Goodness

While a full AV pacemaker is not as rare, this particular example was just too pretty to pass up.

Beautiful clear spikes with the correct waves following right behind. I love it when a plan comes together.

I'll see if I can track down the strip that showed nearly every rhythm the patient was throwing that night. Until then, back to our regularly schedule non-educational programming.

After an exceptional day in the operating room, I realize this list is definitely due, and perhaps will be added to over time.  It focuses on my dislikes at the hospital.

• Standing on power cords.  This robs me of my sense of stability and balance.  It's remarkably uncomfortable.
• Trying to put a forced-air warming blanket on a patient after the surgeons have draped.  Although this causes me no direct pain, it is amazingly annoying and inconvenient, especially compared to how easy it is to put on the warming blanket before draping.
• Pushy surgeons. Surgeons are pushy for a number of reasons, but they usually fall under the categories of 1) Shortsightedness, 2) Rudeness, and 3) Bullheadedness.  I will further explore these in proceeding bullet points.
• 1) Shortsightedness.  Often surgeons are pushy because they want to get the case started.   They believe that the extra ten minutes it took me to get an EKG before bringing the patient in the room because their patient was not adequately prepared is somehow MY delay and this gives them the right to be pushy.  They do not realize that I am trying to HELP them take care of the patient, that it is THEIR fault the patient was not adequately prepared (Why is it so hard for a medical doctor to realize that a patient with coronary artery disease needs an EKG before surgery???), and that if something bad happens because a patient was not adequately prepared, it is MY fault legally because I succumbed to their pushiness.
• 2) Rudeness.  This happens far less often than it used to, but I'm still amazed at how a surgeon will stroll in and INTERRUPT my interview with a patient without even acknowledging me.  I am a physician, and this shows absolutely no respect. I have a policy now of either saying, "Excuse me, you just interrupted me," or just leaving, telling the surgeon on my way out, "I guess I'll come back when you're finished."  This will usually bring an apology.
• 3) Bullheadedness.  Please do not tell me that I need to transfuse blood or start an arterial line when any anesthesiologist would balk at exposing a patient to unnecesary risk.  If you understood the valid medical reasons for doing things that anesthesiologists do, and if you presented such a reason in a nonconfrontational way, then sure, we can talk about it and consider it.  But when you are bullheaded about wanting me to do something stupid, and I choose to be neither bullheaded nor passive-aggressive back to you, then that is not time to persist in your bullheadedness.
• Loud noise.  Today we had jackhammers in an adjacent floor for the better part of the day.  The subway workers manage to work at night and the weekends...why can't hospital construction workers?
• Loud noise.  Nurses with loud voices deserve their own bullet point.
• Loud noise.  Surgeons with loud iPods get another bullet point of their own.
• Lack of awareness.  There are critical times in surgery.  I do my best to focus with the surgeons at these times.  From my end, induction of and emergence from general anesthesia are critical times.  This is not the time to laugh and joke and turn up your iPod.  I will ask you to turn it down.  And I notice the surgeons who stand quietly and attentively at the bedside while I induce and intubate a patient.  Often, those are the surgeons I would choose to send my family to.
• Making a mockery of safety.  During the surgical "time-out", I stop what I'm doing and actively listen, often voicing agreement afterward.  Surgeons who do the time-out with the attentiveness of a 6-year-old in church scare me.  They seem to think that operating on the wrong side of the body is a thing that happens to Other Surgeons.
• Nurses who do not listen during report.  I may have just spent eight hours ensuring that a patient lives through anesthesia and surgery.  I may have even made a little extra effort to make them wake up without pain and nausea.  Sometimes I take steps to prevent untoward cardiac and pulmonary complications.  If I feel like it, I manage the patient's fluid balance and blood counts.  I listen constantly to the beating of their heart, I watch the contours of their arterial pulsatility, I monitor the electrical activity of the heart.  I pad pressure points.  I secure arms so they don't fall.  I paralyze patients and reverse the paralysis.  I make sure necks stay neutral.  I tape eyes closed--sometimes with lubricant inside--to make sure their are no corneal abrasions.  I suction out the stomach to prevent nausea and aspiration.  I measure urine output.  I keep my patient warm.  I comfort and assure patients immediately before surgery.  I answer questions.  I introduce myself to family members.  If after doing all these things I want to take two minutes to tell you about OUR patient, please take the time to listen closely.  After all, I might tell you something important.
• The Emergency Department.  This is the most chaotic, most terrible place in the hospital.  I cannot imagine my hospital's ED ever being called secure, controlled, stable, or peaceful.  There are sick bays.  There are stretchers lining the halls.  There are large families crowded around loved ones.  There are people there for marginal complaints.  One's attention is constantly pulled from one thing to another.  Here, one will encounter that ghastly combination of ADHD physicians, type A aggressive nurses, puking patients, blunt security guards, and a constant, rumbling cacophany.
• Lack of professionalism.  Just because you are a surgeon doesn't mean you need to curse in every sentence.  Just because you are a surgeon doesn't mean you need to talk about your sexual conquests in the operating room.  Just because you are a surgeon doesn't mean you need to talk about how your patient is too fat, too hairy, too ugly, or too annoying.  I will stand up for my patient.
• Scrubs that do not fit well.  Just because more than 50% of Americans are overweight does not mean that scrubs should be designed in "square" proportions.  (Small = small waist and short legs, XL = huge waist and long legs.)  I cannot stand bunching up my wasteband and a crotch seam that comes down to my knees; nor can I stand legs that are too short.

Wow.  This post is far longer than I intended it to be.  The feelings just kept coming!  And the picture, if you're wondering, relates to the last bullet-point.  I thought it was worth a smile!

ABC of Clinical Electrocardiography

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Studies have shown that stimulant medications like those used to treat ADHD can increase heart rate and blood pressure. These side effects are insignificant for most children with ADHD; however, they're an important consideration for children who have a heart condition. Certain heart conditions increase the risk for sudden cardiac death (SCD), which occurs when the heart rhythm becomes erratic and doesn't pump blood through the body.

But before I introduce you all to the man, the myth, the legend that is Andrew Kelly-Hayes, I would like to take a moment to delve a little deeper into what this reality show is all about. By now, most of y’all have seen the commercials for I Survived A Japanese Game Show or have heard the word of mouth. What is clear from these ads, and the water-cooler talk, is that the major concept behind this latest reality offering involves running 10 young Americans through the gauntlet of bizarre and hysterical challenges that Japanese game shows are famous for. What has not been made all that clear, however, is that the other major hook in this show is how these 10 contestants navigate through a totally foreign land and culture, as they live and compete together. The early buzz on the show is that the “house mother,” Mamasan, is quite the pisser, and has been described as a “pot-stirrer.” This I like. The fact that some of the show will be devoted to the contestants’ day-to-day in Japan, all under one roof, is fantastic; especially because that will allow the force of nature that is Andy’s personality to come shining through the television, regardless of how the show is edited. Speaking of the editing process, I don’t envy the guy who is in charge of that; for I am sure that there will be some priceless gems from Andy that will inevitably end up on the cutting room floor.

So now it is time to properly introduce Andrew Kelly-Hayes to you, my faithful readers. Let me start by telling a little story of how we all met this character who became one of our dearest and most loyal friends. It was in early September and the first weekend of the Fall semester way back in 1998, that we threw a legendary, 12-keg, toga party at our off- campus house on Warren Square. We had people manning the door in order to maintain proper crowd control, as well as enforcing the toga dress code. A few hours into the revelry I noticed that a barrel of a man, toga-clad, and sporting a silver helmet securely strapped to his chin, had taken up a post, checking people at the door. My initial reaction was the same as some of my friends, “Who the fuck is this guy, making himself quite at home?” My next thought was, “And what is up with that fuckin’ helmet?” I never really did figure out the whole deal with the helmet. But by the way that Andy bounds through life, like a runaway freight-train, it is probably a good safety precaution. Years later, when Andy visited me in Connecticut, and we went out one night to Toad’s Place in New Haven, he tried to enter the club with his helmet on. While the bouncer seemed cool enough with the unusual headwear, Andy was rebuffed by the police officer at the door. So Andy did the only thing he could do: he checked his helmet with the coats. You should have seen the look on the coat-check girl’s face. I think her exact words were, “This is a new one.”

Although my first reaction to this crazy freshman was apprehensive at best, in a matter of hours, Andy had ingratiated himself with our crew; and 10 years later we are happy and proud to call him our friend. Andy has that special way about him: upon meeting him, you wonder if you had known one another in a previous life; because when you meet Andy, he acts and treats you like he’s known you for years. Andy doesn’t have time for that getting-to-know-you bullshit. It’s quite refreshing. He’s the consummate “people person;” and he’s always looking to lend a helping hand. Friends of our friends became Andy’s friends, and remain so.

Over the next few years of college, Andy was at the center of some of the funniest stories you will hear. And in the years since, few things bring me and others more joy than to recount these hilarious events over a beer or two or ten. Here are some of the highlights:

Next week will not be the first time Andy has appeared in a reality show. During college, he was a contestant on the MTV program called FEAR, in which 6 people must complete a series of tasks, or “dares,” over the course of two nights at a haunted location. Andy, of course, stole the show. In the first clip, Andy is charged with investigating a bathroom where a man was killed. Notice the way Andy comes flying through the door after he completes his dare, and almost knocks over the dude standing near it.

As Egon Spengler, Ray Stantz, and Peter Venkman will tell you, what Andy meant to say was, “I’ve got my PKE, bitch!” confusing the Psycho Kinetic Energy meter with the more common EKG, which is an acronym for the electrocardiogram that measures the electrical activity of the heart. Close enough; and funny as shit!

And in this second clip from the show, Andy is solely responsible for psyching up his fellow contestant, convincing him to follow through with his spooky task, and thus helping the kid win his share of the prize money. Like I said, Andy is all about helping other people.

When we in Jamaica, on spring break, after swimming naked under the glass-bottomed boats that frequented the little cove surrounded by a few bars and restaurants, Andy proceeded to run naked up the stairs carved into rocky cliffs, and continued his lap through the ‘Pickled Parrot’ establishment as the patrons cheered him on. From my vantage point, from atop a cliff, as Andy ran through the throngs of people, triumphantly swinging his swim-trunks like a Steelers “Terrible Towel,” it looked like they were doing The Wave as he passed them by. The crowd continued to cheer as Andy finished his streaking by leaping off the highest cliff of the cove. The crowd fell silent as he fell the forty or so feet, still swinging his shorts; only to erupt in a roar of cheer when he safely splashed into the clear blue water below. Classic. Absolutely classic.

Andy is also quite renowned for his dancing skills as well. For a big man, he is remarkably light on his feet. We all will never forget that time at Leon’s Bar when Andy climbed atop a pool table to perform the “Buffalo Bill” dance from Silence of the Lambs; and then proceeded to fall flat on his face on the dismount, pants still around his ankles. “And you wanna be my latex salesman?” And then there was our wedding; where Andy was tearing up the dance floor like a whirling dervish right before tearing up his pants after performing an impressive split.

So there you have it. This has been just a small slice of the Andy pie; and the stories above merely scratch the surface. And like the following bios on him regarding the show, while I hope to capture his essence, I know I hardly do him justice:

" Andrew Kelly-Hayes, a 28-year-old radio sales consultant from Boston, MA. With his hilarious stories and off-the-wall energy, this flip flop-wearing funnyman could be a long-lost Belushi brother. Whether he's schmoozing old ladies at Bingo, harassing strangers while on "Smile Patrol" or joining his college cheerleading team to meet hot girls, Andrew has a reputation for being a nut."

"Originally from Boston, Massachusetts, Andrew Kelly-Hayes is your typical resident funny man. This radio sales consultant has a degree in journalism and communication and is one big ball of energy and humor. He always has a hilarious story up his sleeve to tell an unsuspecting stranger, whether its old ladies at Bingo or hot cheerleaders in college. Indeed, Andrew’s reputation as a nut goes a long way."

Besides being a really funny, outgoing, fearless guy, he’s also very intelligent, and one of the sweetest, most caring and loyal people you will ever have the pleasure of knowing. So set your TiVos, people, because Andy is coming to primetime. I hope y'all are psyched for the show. And here’s hoping he wins the whole fucking thing, and the 25,965,000 Yen.

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