Steroids, EPO, and Other Performance Enhancing Drugs – On Lance Armstrong, Barry Bonds, and American Culture. Part 1 of 3.

Before we get started, let’s begin by defining a few basic terms to make sure that we understand them before we dig any deeper. Oh, as an aside, “The Cannabinoid Hypothesis” is free on Kindle from 19 JUN 2013 to 23 JUN 2013 so grab a copy if you like dark medical fiction!

Hormone – A long-acting chemical messenger. A hormone is like a biochemical “office memo” that is produced by an organ somewhere in the body, travels through the bloodstream to reach the “mailbox” of a distantly located target organ, and then tells the target organ what to do. For instance, the biochemical messenger thyroid stimulating hormone is produced by the pituitary gland (a pea-sized gland in your brain), travels through the bloodstream to the thyroid gland (located in your lower neck), and then tells the thyroid gland to produce thyroid hormone – a hormone that has a plethora of effects including regulating your metabolism.

Hormonal Cascades – You’ll notice that both thyroid stimulating hormone (TSH) and thyroid hormone are hormones (thanks genius, right?). Thyroid hormone travels from the thyroid gland through the bloodstream and then acts on just about every other organ in the entire frickin’ body. This is a common and important theme. Most hormones act in cascades (hormone A effects the production of hormone B, hormone B effects the production of hormone C, etc.) and some of these cascades can be really long and complicated – don’t worry, this is a blog not a textbook and we’re going to stick with the meat and skip the potatoes! Knowing what a hormone is and what a hormonal cascade does is important because most of the performance-enhancing drugs (PEDs) that we’re going to discuss today are hormones.

One final comment/disclosure: I strongly believe that criminally prosecuting (persecuting?) the average Joe for using PEDs is a gross violation of personal liberties and, frankly, an irrational policy. I absolutely do not advocate the recreational use of any of these substances and I DO believe that athletes who surreptitiously use PEDs to gain an unfair advantage over their competitors should be severely punished for the same reason that a baseball player who corks his bat should be punished – it’s cheating. With that said, putting Moe the College Kid in jail for using steroids to get bigger biceps doesn’t make a lot of sense in my book – he’s not hurting anyone except for himself, and even that is debatable. And yet American society has no problem with Susie having a major elective surgery to enlarge her breasts and to reduce her nose, no problem with selling cigarettes at gas stations, and no issue with glamourizing boozing on national television during family programming like the Super Bowl…

Anabolic-Androgenic Steroids

Anabolic-androgenic steroids (AAS) cause muscle growth (“anabolism” roughly means “growth”) and also result in the development and accentuation of male sex characteristics (the androgenic effects—growing a beard, etc.). The term “steroid” simply refers to a common chemical structure/backbone that is shared by glucocorticoids, mineralocorticoids, and sex hormones – all of which are produced from choleSTEROL.  In other words, not all steroids are AAS – actually most aren’t. When your kid was prescribed steroids for his asthma exacerbation he was prescribed cortiocosteroids (aka: glucocorticoids), which are anti-inflammatory stress hormones that actually are catabolic (catabolic roughly means “causes tissues to shrink”). Mineralocorticoids are extremely important regulators of sodium, potassium, and blood volume while estrogens and progesterones are the female sex hormones.

So returning to AAS, these drugs are all derivatives of the major male sex hormones, DHT and testosterone. Because both DHT and testosterone are highly androgenic — causing acne, hair growth in generally unwanted places, and deepening of the voice (etc.) — drug companies in the early half of the 20th century tried to develop derivatives that would retain the anabolic properties of the natural male sex hormones minus the undesirable androgenic side-effects. Dozens of derivatives were produced and here is a listing of some of them (these are all injectable drugs; we’ll talk about oral AAS in a moment):

Nandrolone Decanoate (aka: Deca) – The closest that the drug companies have yet to come to a purely anabolic steroid that is void of androgenic properties. This drug was formerly very popular among athletes but it has lost favor because its metabolites are detectable in the body for up to 18 months. Unlike most AAS, nandrolone isn’t metabolized to estrogen. The reason that AAS abusers get bloated is because most AAS are converted to estrogens before they are eliminated from the body and, as every woman knows, estrogens cause bloating.

DECA_QV_300[1]

This is an image of a bottle of Mexican veterinary nandrolone decanoate (aka: Deca). The “300” on the label means that it contains 300mg of nandrolone decanoate per milliliter of the oil solvent. Nandrolone is injected intramuscularly.

Testosterone Cypionate and Enanthate – These drugs are simply testosterone that has been conjugated (chemically linked) to a fatty ester. The fatty ester makes the testosterone less soluble in body fluids for the same reason that a drop of fatty oil floats on the top of a glass of water. This slows the active testosterone’s release into the bloodstream. Testosterone that isn’t linked to a fatty ester needs to be injected every day because it is rapidly absorbed into the body after being injected. In contrast, testosterone esters are released over the course of 3 days to several months, depending on the size of the fatty ester, allowing them to be administered much less frequently than straight testosterone. Sustanon is a well-known form of testosterone that is a mixture of four different types of esterified testosterones – one of the esters is released rapidly (testosterone propionate – released over the course of 3 days or so), two of the esters hang around in the body for a few weeks, and the final ester has a half-life of 4-6 weeks (testosterone undecanoate).

These are just a few examples of the plethora of anabolic hormones that the pharmaceutical industry has developed over the decades, but they all have one major drawback, they must be injected and nobody likes to get a shot. The reason that you can’t take testosterone cypionate or nandrolone decanoate orally (at least not if you want it to work) is that these drugs are broken down by the liver before they make it into systemic circulation — in other words, before they reach the rest of the body. The drug companies solved this dilemma by chemically modifying testosterone derivatives via a process called 17-alpha-alkylation. What this means in English is that the testosterone derivative has been chemically modified to make it much harder for the liver to break it down – the downside of this is that 17-alpha-alylated drugs are toxic to the liver. A few examples of orally-active 17-alpha-alkylated AAS are D-bol (aka: dianabol), Anadrol, and Anavar. All of these drugs have the potential to seriously damage the liver.

 3956372_f260[1]

This is dianabol (D-bol) produced in Thailand — often referred to as “Thai pinks.” D-bol is a oral 17-alpha-alkylated anabolic steroid that is toxic to the liver. It also has a particularly high affinity for aromatase, the enzyme that converts some anabolic steroids to estrogen (but not all of them), resulting in the classic “moon face” and bloating of anabolic steroid users.

The medical uses of AAS include: 1. hormone replacement in men with disorders of the endocrine (hormone producing) system; 2. for a rare disease called hereditary angioedema; 3. to enhance healing in some surgical patients (especially severely burned patients); 4. and to encourage weight gain in people with wasting diseases like cancer and AIDS. AAS are generally pretty safe when used under a physician’s supervision, even when they are used for years and years without respite. Common side-effects include increased acne, increasing the rate of the benign enlargement of the prostate that naturally happens over time in all men, increasing the rate of hair loss on the scalp in men who are genetically predisposed to male pattern baldness, increased male pattern hair growth in places where most people don’t want it (the back, the shoulders, etc.), and a decrease in good cholesterol (HDL) with a simultaneous increase in bad cholesterol (LDL). These cholesterol abnormalities can increase the risk of heart disease if a person chronically uses AAS (we’re talking years to decades of use in most cases).

 hairy_back[1]

A bit of humor. While steroid use dose cause hair growth in undesirable places, including the back, this gentleman clearly has a genetic disorder of some sort (a bit of dark medical humor). Female users of anabolic steroids (yes, they do exist) can become masculinized and grow beards, an enlarged clitoris, etc.

Recreational users of oral AAS can cause liver cysts and these cysts can, albeit extremely rarely, rupture and bleed. On rare occasions this can be fatal, but the same side-effect can also occur (again, rarely) with birth control pills – orally-active female hormones. Oral AAS are toxic to the liver and prolonged abuse can absolutely cause liver damage. The biggest dangers of injectable AAS are infection due to poor injection technique, sharing needles (yes, I am aware that this is really uncommon among steroid users), and due to contaminated drugs straight from the factory – something that can occur with medications produced by reputable pharmaceutical companies but which is particularly a risk for illicit AAS users because many of the drugs that they use are actually veterinary drugs produced in shady factories in Mexico. Long term use of AAS causes the body to quit producing its own androgenic hormones. Since the testicles produce androgens in males, long term use (and/or abuse) of AAS causes your nuts to shrink! The common belief that AAS shrink the penis is not true, by the way.

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Despite the widespread conviction in The United States that AAS abuse can cause cancer and “roid rage,” the scientific literature doesn’t confirm this and it probably isn’t true*. A very common “side-effect” of AAS abuse is muscle growth – anyone who tells you that they don’t work is either lying to you or has never opened the pages of a bodybuilding magazine while killing time in the checkout aisle at the grocery store. This muscle growth can actually be a problem in serious abusers of AAS because their muscles often grow faster than their tendons (the connective tissues that attach muscles to bones), predisposing steroid abusers to tendon ruptures – a potentially serious type of injury that can sometimes result in permanent disability. Other problems with walking around weighing 50 or 100lbs more than your body is naturally supposed to weight included an elevated blood pressure, strain on the heart, and premature joint damage that can lead to arthritis.

 Bicepstendon10[1]

A ruptured right biceps tendon — notice the balling of the right biceps compared to the left biceps.

As I said before, using prescription drugs without a physician’s supervision is a really bad idea. With that said, the common notion the AAS are deadly drugs that ruin lives is also largely a fiction. Used medically, AAS are very safe medications and even gross abuse rarely causes major health problems. Can abuse of AAS cause health problems? Absolutely! I’m just saying that most people who abuse these drugs most commonly suffer from rather minor side-effects at most and that the stereotypical portrayal of deadly “steroids” doesn’t have a very sound basis in scientific reality. If a patient came into my office and said, “Doc, I use steroids, I smoke (a legal poison), and I frequently drive around town with a blood alcohol level of 0.07 (very dangerous, but also legal) – which should I quit first for my health?” I’d tell him that quitting smoking was priority #1, quitting impaired driving was priority #2, and quitting AAS abuse was a distant third.

West_Coast_Daddy_Re_Morph_by_BigTeenBodybuilder[1]

In case you were wondering, yes, both of the bodybuilder images have been enhanced to make them look even more ridiculous — to each his/her own!

Okay, so that’s anabolic-androgenic steroids. Next time we’ll cover EPO (erythropoietin) and in Part #3 we’ll cover legal performance enhancing supplements including creatine, HMB, nitric oxide boosters, and whey protein. Hope to see you there!

*There have been a few studies that demonstrated increased emotional lability in AAS abusers. However, these studies suffered from small sample sizes and from numerous other flaws. One of the major problems with studying the mood effects of AAS abuse is that it’s safe to assume that most people who want to look like a bodybuilder in the first place have pre-existing psychiatric issues. Studying the emotional effects of AAS abuse in this patient population is sort of like studying the psychiatric effects of dieting using a sample of anorexics – you’d undoubtedly conclude that dieting causes severe psychiatric disturbances because everyone in your sample is already disturbed! AAS probably have some psychiatric side-effects; in fact, it would be rather shocking if they didn’t since people with high levels of male hormones (men) tend to be different psychologically than people with lower levels of these hormones (women). However, the psychotic “roid rage” syndrome is completely unproven and, in my experience, almost certainly a myth. There are over 1 million current and former abusers of AAS in The United States alone and “roid rage” attacks, while a convenient legal defense strategy in the courtroom, are about as common as Big Foot sightings – when is the last time that a legitimate one happened in your town, because I guarantee you that your town has steroid abusers living in it…

References:

Deca Image: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=nandrolone&oq=nandrolone&gs_l=img.3..0l10.70421.72422.0.72589.10.10.0.0.0.0.71.472.10.10.0.eqrwrth..0.0…1.1.17.img.ut8Pss9tOno&bav=on.2,or.r_qf.&bvm=bv.48175248,d.dmQ&fp=13dc04e8b48effa6&biw=922&bih=531&facrc=_&imgdii=_&imgrc=dL1dULNpDGqX7M%3A%3BO6GuoanSUrNvYM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252Fc%252Fc5%252FDECA_QV_300.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ADECA_QV_300.jpg%3B405%3B586

Guy with Ridiculously Large Lats Image: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#facrc=_&imgdii=_&imgrc=hZsOCJchxdDYYM%3A%3BBYZg-6aMeou4eM%3Bhttp%253A%252F%252Ffarm1.staticflickr.com%252F104%252F287569669_0670f4d966_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fmawkroy%252F287569669%252F%3B550%3B367

Guy with Hairy Back Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Funiqueblogofawesome.blogspot.com%2F2012%2F07%2Fyou-crazy-little-coconuts.html&h=0&w=0&sz=1&tbnid=fqWDyLcy9RC-TM&tbnh=192&tbnw=256&prev=%2Fsearch%3Fq%3Dhairy%2Bback%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=hairy%20back&docid=jidzrZkryZisOM&hl=en&ei=8pPDUYHbMYbo8wS55ICACA&ved=0CAEQsCU

D-bol Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fhubpages.com%2Fhub%2FDianabol-Side-Effects&h=0&w=0&sz=1&tbnid=UEOCRGyduzQErM&tbnh=173&tbnw=208&prev=%2Fsearch%3Fq%3Dd-bol%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=d-bol&docid=hLK3uWlhS1cQPM&hl=en&ei=tpTDUZLCO4bs8wSyuoD4Cw&ved=0CAEQsCU

Bicep Tendon Rupture: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=tendon+rupture&oq=tendon+rupture&gs_l=img.3..0l9j0i5.2096.4771.2.4923.17.16.1.0.0.0.103.917.15j1.16.0.eqrwrth..0.0…1.1.17.img.3kvqHsEqgqA&bav=on.2,or.r_qf.&fp=13dc04e8b48effa6&biw=1600&bih=752&facrc=_&imgdii=_&imgrc=kOrcm-fbmFMy-M%3A%3B1Z0qBbmEyEePWM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F8%252F8d%252FBicepstendon10.JPG%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ABicepstendon10.JPG%3B2970%3B2183

Guy with Ridiculous Pecs Image: http://bigteenbodybuilder.deviantart.com/art/West-Coast-Daddy-Re-Morph-164856324

 

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not necessarily reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

Doc’s Books!

The Life of a Colonial FugitiveIntrusive Memory E-CoverMedical School 101The Cannabinoid Hypothesis

Screening Smokers and Former Smokers for Lung Cancer – Hot off the Press!

Note: The United States Preventative Services Taskforce recently decided to recommend screening smokers and former smokers as described in this article. The final guidelines are still being formulated, but a consensus has been reached and this is going to happen in the near future. Remember, you heard it here first!

Lung cancer is the #1 cause of death from cancer in the world and this lovely disease was exceedingly rare before cigarette smoking became widespread in the 19th century. If you are a smoker, a former smoker, or a person who has had prolonged exposure to secondhand smoke (e.g. bartenders, etc.) then you are at risk of developing and dying of lung cancer, a really terrible and often painful way to go. Even former smokers are at risk of this disease – as a general rule your risk of dying of lung cancer returns to “about” the level of a lifelong nonsmoker 20 years after you smoke your last cigarette, but it never actually returns to zero, with zero actually being pretty close to the chance of developing lung cancer in a person who has never smoked and who didn’t live or work in a smoky environment.

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Like most cancers, catching lung cancer early greatly increases the chance that it will be curable, usually by surgical removal of the tumor, something that is essentially impossible in late stage lung cancers because by then the cancer has metastasized (spread) all over the body from its initial site. In order to treat an early stage cancer you have to be able to find it and that has been a major problem in lung cancer because the lungs aren’t exactly a part of the body that you can easily see in the mirror and early stage lung cancers are usually too small to cause any symptoms. By the time lung cancer is large enough to cause symptoms (weight loss, breathing difficulties, coughing up blood, etc.) it’s usually too late for physicians to do anything about it other than to treat the person with palliative support – i.e. to make them as comfortable as we can and to perhaps moderately prolong the inevitable.

 fatal-lung-cancer[1]

Screening tests are always a double-edged sword. If we wheeled every former smoker to the operating room and cracked their chest, examined their lungs from the outside, and then stuck a bronchoscope down the patient’s throat to examine the inner aspects of the lungs we probably could diagnose most lung cancers in the early stage. Obviously this is a bad idea because the risk of routinely doing this hypothetical screening procedure would outweigh the potential benefit – we’d detect a lot of early stage lung cancers but more people would probably die as a result of the screening procedure than we would save from cancer (not to mention that this method of “screening” would completely bankrupt our healthcare system and leave no money for interventions that actually make sense)!!! As such, the key to developing a good screening test to detect early stage cancers while they are still potentially curable requires that we develop a test in which the harms of the test are greatly outweighed by the benefits of performing the screening protocol. It also helps to develop a test that is affordable because the reality of life is that both money and medical resources are finite commodities – anyone who doesn’t think that rationing of healthcare isn’t both a reality of our current system and an essential aspect of it is truly a fool (everything in life is rationed except air, and even that isn’t true on submarines!).

The May 23, 2013 issue of the prestigious medical journal, The New England Journal of Medicine, reported the results of The National Lung Screening Trial which studied low dose CT scan as a screening method for lung cancer in smokers and former smokers. A CT scan (aka: CAT scan) is a machine that zaps your body with a bunch of X-rays from lots of different angles and then feeds the information from these X-rays into a computer which reconstructs them into a 3D image of, in this instance, your chest and lungs. In this 10 year study, which involved over 50,000 participants, low dose CT was compared to chest X-ray (a single X-ray instead of dozens) as a method of screening smokers and former smokers who were in their mid-50s to mid-70s for lung cancer – since chest X-ray had already proven to be a lousy way of screening for lung cancer they researchers were in effect measuring low dose CT screening vs. not screening for lung cancer.

 

The key to determining whether a screening test is worth its salt is determining whether the test provides a reduction in mortality (risk of dying). Chest X-ray had already proven not to reduce mortality so it should liven every smokers and former smokers day to learn that in this impressive clinical trial screening with low dose CT decreased mortality from lung cancer by 20%! That’s great news but don’t rush out and beg for a low dose CT scan quite yet because the ultimate verdict on using this diagnostic test for lung cancer screening is still out for several reasons. First, low dose CT scan detected most, but not all, of the lung cancers in the patients who were screened – 6% of lung cancers were missed by the screening test but that’s still pretty darn good. Second, even though “low dose” CT uses less radiation than full dose CT the procedure still zaps your body with a substantial amount of radiation which could conceivably induce a new cancer down the line. Since the people who were screened in this study were mostly older folks this is less of an issue than if low dose CT was being used for screening in younger people; nonetheless, it’s definitely a valid consideration because you never want a CT scan for any reason (because of the radiation) unless you really need one. Third, even though most of the lung cancers in the screening cohort were detected this detection came at the expense of picking up a ton of false positives. For every potential lung cancer that was detected only 6% of them actually turned out to really be cancer! The other 94% of the detected “scary lesions” turned out to be benign but many of these people still underwent lung biopsy (sticking a needle through the chest and into the lungs) and/or bronchoscopy (shoving a scope down your throat and into your lungs while you are sedated) and both of these confirmatory procedures can result in some really nasty side-effects, like a collapsed lung or a nasty case of pneumonia. Finally, there is the issue of whether screening for lung cancer with low dose CT is cost-effective because no matter how great a test is if we can’t afford it as a society it isn’t a good screening test.

 Ct-scan[1]

A CT Scanner. The table moved back and forth through the “donut,” which spins around the patient and takes a bunch of X-rays from different angles.

imagesCAY2SCD8

A Normal CT Scan of the Chest: 1. Right Lung, 4. Aortic Arch, 5. Left Lung (you’re viewing it from the aspect of the patient’s feet while they’re lying down), 7. A Vertebra of the Spinal Column (“backbone”), 8. A Rib.

In a nutshell, screening smokers and former smokers for lung cancer with low dose CT is looking very promising but more studies need to be done before it becomes a routine part of medicine. Remember, if you smoke the #1 thing that you can do to improve your health is to quit smoking! In addition to lung cancer, smoking predisposes you to heart attacks, high blood pressure, strokes, bladder and kidney cancer, mouth and throat cancer, COPD (formerly known as emphysema – a terrible disease to live with), bone loss, and a litany of other badness that is avoidable by quitting! I know that it’s hard to quit, that’s why the tobacco companies are so wealthy, but if you smoke please think long and hard about it because it really is very very very important! Your doctor has lots of medications that can assist smokers in quitting and many of them help more than you would think. But that doesn’t change the fact that if you aren’t truly committed to quitting smoking you won’t – finding the will to change your life always has been and always will be both the most difficult and the most important medical decision.

 

References

1.       The National Lung Screening Trial Research Team. Results of Initial Low-Dose Computed Tomographic Screening for Lung Cancer. The New England Journal of Medicine. 23 MAY 2013.

2.       http://www.cancer.gov/newscenter/newsfromnci/2011/NLSTprimaryNEJM.

3.       Rigotti NA, Rennard SI, and Daughton DM. Benefits and Risks of Smoking Cessation. In: UpToDate. Accessed 14 APR 2013.

4.       Image 1: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=marlboro+man&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=dN20UZnmLanHywHy1oHICw#facrc=_&imgrc=KhBna-iUrhIK_M%3A%3BKTd40oBkDDDcsM%3Bhttp%253A%252F%252Ffarm3.staticflickr.com%252F2470%252F3564450933_99daed43b2_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fbeaumontpete%252F3564450933%252F%3B1200%3B900

5.       Image 2: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fourawesomeessay.wikispaces.com%2FHow%2Bsmoking%2Baffects%2Bhealth&h=0&w=0&sz=1&tbnid=UFDO02mpgYV3rM&tbnh=201&tbnw=251&prev=%2Fsearch%3Fq%3Dlung%2Bcancer%2Bfrom%2Bsmoking%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=lung%20cancer%20from%20smoking&docid=D3JE6-ovyd9paM&hl=en&ei=Gd60UZ-QEoONrAGSwYDgCw&ved=0CAEQsCU

6.       Image 3: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=marlboro+man&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=dN20UZnmLanHywHy1oHICw#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=CT+scanner&oq=CT+scanner&gs_l=img.3..0l10.62728.64210.2.64374.10.10.0.0.0.0.162.1080.5j5.10.0.crnk_timepromotionb..0.0…1.1.16.img.rTEBuId2TYA&bav=on.2,or.r_qf.&fp=dceb5884aff80566&biw=713&bih=486&facrc=_&imgrc=fY-O8OH8T9VcVM%3A%3BkT6sJ6Oy56F4CM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F3%252F35%252FCt-scan.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ACt-scan.jpg%3B901%3B605

7.      Image 4: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=marlboro+man&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=dN20UZnmLanHywHy1oHICw#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=chest+CT&oq=chest+CT&gs_l=img.12…0.0.0.4004.0.0.0.0.0.0.0.0..0.0.crnk_timepromotionb..0.0…1..16.img.g02h2J4EtVE&bav=on.2,or.r_qf.&fp=dceb5884aff80566&biw=1366&bih=622&facrc=0%3Bchest%20ct%20aortic%20arch&imgrc=_

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The Life of a Colonial FugitiveIntrusive MemoryMedical School 101The Cannabinoid Hypothesis

Does CPR Work?

The short answer is “sometimes.” The statistics on out-of-hospital CPR according to the American Heart Association show that it doubles or triples a person’s chance of surviving a cardiac arrest, which is pretty impressive. With that said, even in the hospital a person’s chance of surviving a true cardiac arrest is less than 30% and the chances of surviving an out-of-hospital cardiac arrest are closer to 1-2% without CPR and still less than 10% even with CPR (Note: the exact figures are debatable and they depend on a lot of other factors, especially on how fast a city’s EMS service responds to calls). “Cardiac arrest” occurs when the heart stops pumping or stops pumping effectively enough to keep the brain perfused with blood – the purpose of blood being to carry oxygen from the air we breathe and other vital nutrients to the rest of the body. While many of the body’s organs can survive without an adequate oxygen supply for hours, the brain begins to die within four minutes of oxygen deprivation and this is the reason why cardiac arrest is so very deadly, so very fast.

Most people think that the most common cause of cardiac arrest is a heart attack, the death of part of the heart muscle that occurs when a cholesterol plaque ruptures in one of the coronary arteries (the arteries that feed oxygen to the muscle of the heart) and causes the artery to be blocked. That is partly true; heart attacks are the precipitating event of most cardiac arrests. However, the reason that heart attack victims die in the near term is not the heart attack per se, but rather the heart attack causing the electrical pacemaker system of the heart to go screwy – a cardiac arrhythmia. The heart is controlled by the pacemaker system that functions by sending an electrical signal from the top part of the heart (the atria) to the bottom part of the heart (the ventricles) causing the heart muscle to contract and to essentially squeeze the blood in its chambers out through the aorta and to the rest of the body, the brain included. Heart attacks often cause the pacemaker system to malfunction so that instead of one electrical signal telling the heart to beat in a synchronized fashion instead there are multiple electrical signals causing erratic spasms of the heart muscle that do not effectively pump blood. These erratic spasms of the heart (“ventricular fibrillation”) rapidly degrade into a completely non-beating heart (“asystole” – a stopped heart) and the heart attack victim dies.

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The purpose of CPR is to use physical chest compressions to force blood out of the heart and into the brain and the rest of the body, keeping it alive until emergency medical service (EMS) personnel arrive with an electrical defibrillator – a machine that delivers an electric shock that can often be effective in resetting the heart’s pacemaker/electrical conduction system, restoring a normal heart rhythm. CPR is performed by compressing the chest with the resuscitators body weight (transmitted through the arms) hard and fast. The old form of CPR, and the kind that is still used in the hospital and by emergency medical personnel, involved a breathing component but recently published evidence in The New England Journal of Medicine has shown that CPR performed by bystanders for out-of-hospital cardiac arrest is just as good if only compressions are used as the original version with mouth-to-mouth breathing. This is because the blood contains a rather significant reserve of oxygen and circulating this blood with its oxygen with chest compressions can keep a cardiac arrest victim’s vital organs alive for long enough to allow EMS personnel to arrive with their fancy resuscitation tools – oxygen, advanced airways devices, defibrillators, and heart protective drugs. The good news is that it is really easy to learn to perform chest compressions – the American Heart Association even has a 1 minute video to teach you how to do it and the link to this video is here:

http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFactsandStats/CPR-Statistics_UCM_307542_Article.jsp.

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A police officer performing chest compression. The device in the background is an AED and the pads under the police officer’s hands/left arm are the electrical pads that deliver the defibrillation shock current.

While learning how to perform chest compressions is great, what is even better is learning how to use an AED – an automated external defibrillator, an electrical defibrillator that you can learn how to use just by taking a simple class called Basic Life Support (BLS). AEDs are found in most large public buildings – airports, sport’s stadiums, etc. – and they are becoming more widespread every day. BLS classes are taught credentialed by the American Heart Association and they can be found in just about any city, town, and village in America. The class only takes a few hours and I highly recommend taking it, not only to learn BLS techniques like the AED but also to learn how to properly perform chest compressions on manikins because it is possible to seriously injure or even kill someone with chest compressions if they are used inappropriately (this is also true of the AED device).

Defibrillation_Electrode_Position[1]

A diagram of an electrical defibrillation shock delivered by a defibrillator (either an AED or a hospital defibrillator).

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers to check out my books and to support www.leonardonoto.com!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The Life of a Colonial FugitiveThe Cannabinoid HypothesisIntrusive Memory E-CoverMedical School 101