PSYCHIATRIC SKIN DISORDERS — Delusional Parasitosis and Friends.

“Neurodermatitis” is a medical euphemism for psychiatric skin disorders — skin disorders caused by mental illness. This group of disorders includes delusional parasitosis, Morgellons disease, neurotic excoriations, trichotillomania, and dermatitis artefacta. These conditions are different, yet similar in many respects. All of them are diagnoses of exclusion — diagnoses that are only made after intrinsic skin disorders have been ruled out by the physician. Most of these disorders can be spotted for what they are (by physicians) based on the unique pattern and distribution of the lesions. The skin lesions generally only occur in places that the patient can readily reach and the lesions tend to look highly unusual to the trained eye. The history of the patient is also an important piece of diagnostic evidence in most cases — e.g. a patient with other psychiatric diseases who has been to half-a-dozen dermatologists and no one can figure out what the heck is wrong with them. A skin biopsy can also be useful in equivocal cases. All of these disorders are potentially debilitating, and they all tend to be expensive and sometimes impossible to treat.

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An artist’s illustration of the “gross” (as opposed to “microscopic”) appearance of scabies, definitely not a psychiatric disease. Sometimes when you feel like you have bugs crawling under your skin you really do! As with all conditions, remember that just because someone has a mental illness doesn’t mean that they don’t also get physically ill from time to time like everyone else.

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An electronmicrograph of the scabies mite. Scabies is usually treated with a drug called permethrin. Outbreaks are common in nursing homes and also sometimes occur in hospitals and daycare centers.

Dermatitis artefacta is a form of factitious disorder, an intentionally caused medical problem that is self-inflicted to fulfill a subconscious need to assume the “sick role.” Patients with this disorder don’t feel normal unless everyone thinks that they are sick. When you are sick people tend to be nice to you and to give you lots of attention, and this is what persons afflicted with factitious disorders crave. Sometimes people with factitious disorder intentionally cause medical problems in their children. Instead of craving the “sick role” for themselves, these individuals crave the role of “caregiver for the sick.” This is called Munchausens Disorder by Proxy and it is a form of child abuse, probably the worst form of child abuse given the amount of psychological damage that is done to the child victim, which is immense.

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Self-inflicted skin lesions in a patient with dermatitis artefacta.

Delusional Parasitosis, as the name implies, is a delusional disorder. A delusion is a fixed belief that a person continues to believe even in the face of overwhelming evidence to the contrary. In the case of delusional parasitosis, patients are convinced that they have bugs crawling under their skin when they don’t. Obviously someone with scabies does not have delusional parasitosis — they really do have bugs crawling under their skin! A similar condition to delusional parasitosis is substance-induced formication. That’s “formication,” not “fornication” — the term is derived from the chemical “formic acid” that causes ant bites to sting. People intoxicated with stimulants, such as cocaine and methamphetamine, and persons under-the-influence of hallucinogens, such as LSD and PCP, sometimes feel like they have bugs crawling all over them. This is different than delusional parasitosis because the sensation resolves once the drug is out of their system.

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Crack cocaine. A common cause of substance-induced formication.

Morgellons Disease is now considered by most physicians to be a subtype of delusional parasitosis. Instead of delusions of insects crawling under the skin, people with Morgellons suffer from a belief that painful or itchy fibers are erupting from their bodies. Some people with this condition believe that they are contagious, whereas others suspect that they have been inoculated with nanofibers (or microfibers) by the government or by space aliens. The following ABC Nightline clip (courtesy of YouTube) is an interview of the original Morgellons patient, who also is the person who coined the term “Morgellons” in the contemporary context.

I was highly reluctant to put the link to this YouTube video here for reasons that will be obvious after you watch it. I felt significantly less equivocal about it after I learned that the “founder” of this disease is running a website that sells purported “natural cures” for Morgellons, and a lot of other conditions that are of questionable medical veracity. Still, I wish that the kids weren’t in the video… With that said, the video is highly educational on several levels, and even more so in 20/20 hindsight, both for healthcare providers and for laypeople, which is why I have reluctantly decided to share the link.

This video was produced before a pivotal 2008 CDC study failed to reveal a medical (other than psychiatric) etiology of the Morgellons syndrome. The results were published in 2012 — see Reference #4 below. The CDC researchers scoured the medical records of 2.8 million Kaiser Permanente patients, Kaiser being an HMO that is known for good record keeping and that commands a large percentage of the healthcare market in Northern California, an area with a high concentration of possible Morgellons sufferers. The researchers identified 115 patients who met the criteria for possible Morgellons. Of these patients, 41 chose to participate in the study, which was designed to help determine if Morgellons was a new disease or not.

In summary, after an exhaustive study the CDC did not find evidence of a new disease entity. The fiber samples taken from patients with purported Morgellons disease were found to be mostly cotton fibers of the type found in clothing, etc. Most of the patients in the study also had comorbid psychiatric conditions and/or substance abuse problems. This study is a really good example of how the CDC investigates a potential new disease and it is an excellent read if you are into reading that kind of thing (and probably remarkably boring to you if you aren’t into reading medical studies!). Please note that this study absolutely does not say that folks with “Morgellons” symptoms do not have a disease. It just suggests (indirectly) that the condition that they suffer from is a subtype of delusional parasitosis, which is a highly disabling disorder that is potentially treatable with psychotherapy and with medications, particular with a drug called pimozide that is both an antipsychotic drug and a potent antipruritic (anti-itch) medication.

Finally, Neurogenic Excoriation Disorder is a form of Obsessive-Compulsive Disorder (OCD). It usually starts with a person who suffers from both acne and from OCD. People afflicted with OCD have obsessions — disturbing and recurring thoughts — that can be temporarily alleviated by performing a compulsive act, such as excessive hand washing or, in the case of neurogenic excoriation disorder, skin picking. The bad news is that OCD can be highly disabling. The good news is that it is highly treatable with a combination of counseling and psychiatric medication. The medication of choice is generally a member of the SSRI class of antidepressants, which are among the most commonly prescribed medications in the United States and which have an excellent safety profile. Trichotillomania is a related condition in which sufferers feel compelled to pull their hair out (and they do — see image below).

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An image of a person suffering from neurogenic excoriation disorder.

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Trichotillomania.

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 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 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.

REFERENCES

1. Morgellons disease: Managing a mysterious skin condition. http://www.mayoclinic.org/morgellons-disease/art-20044996?pg=1.

2. Gupta, AK. Psychocutaneous Disorders. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins, Philadelphia, PA. 2009.

3. CDC. Study of an Unexplained Dermopathy. http://www.cdc.gov/unexplaineddermopathy/

4. Michele Pearson, et al. Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0029908.  Published: January 25, 2012. DOI: 10.1371/journal.pone.0029908

5. Scabies Image: Walker, Norman Purvis () An introduction to dermatology (3rd ed.), William Wood and company Retrieved on 26 September 2010.

6. Scabies Mite (Electronmicrograph): Author: Kalumet. Date: 06.11.2004. http://commons.wikimedia.org/wiki/File:Sarcoptes_scabei_2.jpg.

7. Neurodermatitis, Wikipedia Image: “Factitious dermatitis” by Neeraj Varyani, Sunny Garg, Garima Gupta, Shivendra Singh, and Kamlakar Tripathi. – This image in Case Reports in Psychiatry Volume 2012 (2012), Article ID 674136, 3 pages doi:10.1155/2012/674136 Case Report Trichotillomania and Dermatitis Artefacta: A Rare Coexistence. Licensed under CC BY-SA 1.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Factitious_dermatitis.jpg#/media/File:Factitious_dermatitis.jpg.

8. Excoriation Disorder: http://en.wikipedia.org/wiki/Excoriation_disorder#/media/File:Derma_me.JPG

9. Crack Cocaine: Uploaded: March 6, 2005 by David.Monniaux. http://en.wikipedia.org/wiki/Crack_cocaine#/media/File:Crack_street_dosage.jpg.

10. Alien Fibers: Morgellons Disease – ABC’s Nightline. Uploaded August 25, 2011. https://www.youtube.com/watch?v=xsiJpuARHcE.

11. John Y.M. Koo. Dermatitis Artefacta. http://emedicine.medscape.com/article/1121933-overview.

12. Trichotillomania Image: http://commons.wikimedia.org/wiki/File:Trichotillomania_1.jpg.

 

What Happened to Anderson Silva’s Leg? Tib-Fib Fractures Explained.

For those of you who don’t know, I’m a huge UFC fan, a practitioner of Brazilian jiu jitsu, and a former (amateur) practitioner of muay Thai. So it should come as no surprise that I’m devoting today’s posting to Anderson Silva’s horrific injury that was suffered during the former champion’s (for six years!) rematch against the man who took his title, Chris Weidman. Everyone who was watching the fight was shocked when Silva broke his leg in half against Weidman’s knee while throwing a leg kick. And let’s start there. A lot of folk’s think that it was an accident that Weidman’s knee happened to contact the former champ’s leg; in other words, that Weidman “got lucky.” He didn’t. The knee block that Weidman skillfully threw is called a “kow bang” and it is one of the most difficult techniques to execute in all of muay Thai, so difficult that I couldn’t even find an uncopyrighted image to show you, having to settle for the similar, but less difficult to execute, elbow block instead.

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An elbow check. The usual way to block a high Thai kick is to catch it with both of your forearms (one is no good because it will likely break). The elbow block is substantially stronger than the forearm block, potentially damaging your opponent’s shin at the same time that it protects your noggin. The problem is that this block is much more difficult to execute than a traditional, forearm block and that missing the block means catching the full impact of the kick with your head!

The kow bang is intended to cause microfractures and pain in your opponent’s tibia (shin bone) so that they won’t be able to continue landing Thai kicks on your legs — the technique just happened to work a little better than expected in this particular fight. The kow bang requires absolutely perfect timing to execute in the ring and the problems with missing an attempted kow bang are two-fold. The first problem is that it is easy to raise your knee too high, resulting in your opponent’s kick slamming full force into your opposite leg, the one that 100% of your bodyweight is resting on. This usually results in a spill hard onto the floor, which in mixed martial arts is rapidly followed by your opponent pounding your face in. The second issue with the kow bang is the opposite problem. If you don’t raise your knee high enough to block the kick then the kick slams right across your thigh, exactly where your don’t want to be taking Thai kicks if you’re planning to make it out of the first round walking instead of limping.

Okay, so that’s what happened in the fight. Now let’s talk about what happened to Silva’s leg from a medical perspective. Let’s first step back for a second and review the basics. The lower extremity (the calf is technically “the leg”) is composed of three major bones and a bunch of smaller ones in the foot (the patella, or knee cap, is really part of a ligament). The femur is the thigh bone and it articulates (meets) the tibia at the knee joint. The tibia is the major weight bearing bone of the leg/calf and it is the bone that you feel when you rub your fingers down your shin. This is also the bone that Thai boxers and UFC fighters use to land most of their kicks, and it is a very strong bone once it has been conditioned by years of training. The fibula is the smaller bone that runs parallel to the tibia and that at its distal (farthest from your body) termination forms that lateral (away from the midline of your body) portion of your ankle joint. The tibia forms the medial (closest to midline) portion of the ankle joint and the parts of these bones at the ankle are referred to as malleoli. Good ahead, reach down to your ankle and feel them!

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A tibia-fibula (“tib-fib”) fracture, similar to the one that Silva suffered last Saturday.

Silva fractured (fracture = break = fracture) his tibia and his fibula above the ankle joint. Fortunately his fracture was simple, which means that the broken pieces of bone didn’t pierce the skin, a really big deal because compound (open) fractures are much more likely to develop terrible infections, especially if you suffer the fracture in a blood splattered MMA ring. What Silva’s doctor did (see below for the link to his press release) was an open reduction, internal fixation to repair the fractured tibia. He then left the fibula to essentially heal on its own, which is okay because the fibula isn’t a weight bearing bone and it’s biggest contribution to the function of the leg is in stabilizing the ankle joint. In fact, orthopedic (bone) surgeons often harvest the shaft of the fibula when they need to replace a more critical piece of bone somewhere else in the body — the forearm, for instance — and the body usually does pretty well as long as the most distal part, the lateral malleolus of the ankle, is left in place.

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A compound (open) tib-fib fracture. Not good.

Open reduction, internal fixation (ORIF) is a surgical procedure during which a broken bone is loosely approximated (put back into place) in the operating room and then a rod is hammered (literally) into the hollow internal cavity of the bone to hold the healing parts of the bone in place. Recall that the insides of bone are filled with a soft marrow. This marrow is fairly easy to suction out, leaving a nice round cavity to shove a sterile metal rod to support the healing bone! The bone fragments and the rod are held together by surgical screws, which are power-drilled into place in the operating room (using a sterile drill), and after 6-9 months the bone usually heals nicely. The rod is left in place, in case you were wondering.

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Status-post open reduction, internal fixation!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 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.

RESOURCES

Muay Thai Image. Courtesy of Wikipedia. http://en.wikipedia.org

Tib-Fib Fracture Films. Courtesy of Wikipedia. http://en.wikipedia.org

Compound Tib-Fib, Courtesy of Wikipedia. http://en.wikipedia.org/wiki/File:Offene_Luxation.jpg

ORIF Films. Courtesy of The University of California at San Francisco School of Medicine. http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fsfghed.ucsf.edu%2FEducation%2FClinicImages%2Flower_extremity_films.htm&h=0&w=0&sz=1&tbnid=I-9_eWuyLrMYlM&tbnh=259&tbnw=194&zoom=1&docid=DXUd9umkQuW6wM&hl=en&ei=yozCUqbXJcrXyAHfzoG4DA&ved=0CAIQsCUoAA

The UFC Orthopedic Surgeon’s Press Release. http://www.lasvegassun.com/news/2013/dec/30/anderson-silvas-doctor-details-surgery-and-recover/

Let’s Talk About Fluids — Intravenous Hydration 101

Hydration may seem like a mundane topic at first, but I assure you that it’s not. When I first entered medical school I was fascinated, and a little bit disappointed, about how much time we spent talking about how to pump salt water through some guys veins. Hell, it was all half of the doctors lecturing us wanted to talk about, especially the emergency medicine attendings! With all of the flashbang drugs we have, and all of the fancy mechanical interventions like respirators, why were these guys so hung up on IV fluids???

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A man dying of cholera.

Well, it turns out that these “doctors” actually DID know what they were talking about and that “little med student me” was really the one who was clueless. Got cholera? Guess what, it’s the fluid loss from the profuse diarrhea that kills you, not the bacteria, which your body will eventually fight off on its own if you don’t die from the dehydration first. Done got shot or blowed up with an IED? Guess what, the reason that the blood loss kills you (primarily) is due to the loss of hydrostatic (fluid) pressure in your blood vessels resulting in circulatory collaspe — replacing that fluid pressure can keep your heart pumping while the docs work to stop the bleeding. So as you can see, fluids are quite important indeed.

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Let’s go back to the basics before we talk about the fancy stuff. We normally replenish our body fluids by drinking water and by eating food and the reason that we need to replace a portion our body fluids every day by drinking is that we are constantly loosing fluid through two processes: 1) sensible fluid loss and 2) insensible fluid loss. Now the “sensible” and “insensible” terms in this case aren’t being thrown around in the way that we use them in the vernacular. For instance, we aren’t talking about it being sensible to lose fluid during a water balloon fight and insensible to lose it by throwing a bottle of water out of a speeding car while school children are skipping on the side of the road. Rather, “sensible” fluid losses are fluid losses that you can see/feel while “insensible” fluid losses are imperceptible. Sensible fluid losses include urination and defecation whilst insensible losses occur in small amounts with every breath that you take and with sweating, which is usually unnoticable unless you’re overheated.

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A urinal. A device invented so that men would stop urinating (a form of sensible fluid loss) onto the toilet seat. The urinal has met with mixed success.

Hydration isn’t just about water, it’s also about electrolytes, especially sodium and chloride. Sodium chloride (NaCl) is table salt and when you dissolve table salt into water the NaCl crystals breakdown into positively charged Na ions and negatively charged Cl ions. These ions are essential to keeping your body running properly. When you lose fluid you lose both water and NaCl and many disease processes wreak their havoc on the body (at least in part) by accelerating this fluid loss. Diarrhea = excessive water and electrolyte loss in the stool. Burns cause excessive fluid loss through the body surface areas that are no longer covered by intact skin. Gunshot wounds cause fluid loss via bleeding. Fevers cause increased fluid loss via sweating and through the lungs. See a common theme here!!!

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Table salt that hasn’t been ground into the fine powder that most Americans are habituated to.

Hang in there, we’re almost to the good stuff, but before we start talking about poking folks with IVs and central lines let’s address one more basic question: how is it possible to die of thrist in the middle of the ocean? Everyone knows that you can’t drink salt water because it will make you sick, but why is that? I mean, the oceans hold over 90% of the Earth’s water! The reason that drinking salt water makes you sick is that ocean water contains 3.5% NaCl whereas human body fluids only contain 0.6% NaCl. The way that your body gets rid of excess electrolytes (including NaCl) and waste products is to flush them out via the kidneys in the form of urine and this process requires water. The concentration of NaCl is so high in sea water that getting rid of the excess salt actually requires more water than the amount that you gain by drinking it. In other words, drinking out of the ocean actually makes you lose more body water in the urine than you have gained by drinking it, the net effect being to dehydrate you faster than if you hadn’t sipped on the sea water in the first place. While some NaCl in the blood is essential for the body to function properly, too much causes bad things like seizures and comas.

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The primary way that doctors replace body fluids is with crystalloid solutions, and the most commonly used crystalloid solution is normal saline. “Crystalloid” sounds like a fancy term but all it really means is water with an electrolyte dissolved in it. Normal saline is water with salt (Salt is a crystal before it is dissolved, right. Salt crystals anyone!) dissolved in it at approximately the same concentration as the levels of salt that are found in your blood. Actually, human blood is 0.6% NaCl whereas normal saline is 0.9% NaCl; but normal saline still is approximately equivalent to human blood plasma (the liquid component of blood) because human blood has other electrolytes in it, albeit in much lower concentrations than NaCl. It’s usually just fine to use normal saline to replace a few liters of fluid but if you have to give more than that sometimes doc will have to add some potassium, magnesium, or phosphorous to the solution to keep your electrolytes balanced. There are also other crystalloid solutions that come prepackaged with physiologic doses of electrolytes but now we’re getting way beyond the scope of my little blog!

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A bag of normal saline. Normal saline usually comes in 1 liter bags but they do make smaller and larger bags for specialized purposes.

Human blood is composed of approximately 55% plasma (essentially salt water) and 45% blood cells, primarily oxygen carrying red blood cells. Since all healthy people walk around with way more red blood cells than they actually need (not necessarily true in anemic or chronically ill people), most dehydrated people do pretty well when their plasma volume is replaced with crystalloid solution. People who have suffered massive blood loss or who are anemic to begin with may need a blood transfusion. But it takes time to match blood products and the loss of hydrostatic presssure in the blood vessels is what kills you in the shortrun anyway, so volume replacement with fluids is pretty much the first step for any severely dehydrated or bleeding patient (yes I am aware of the military’s tenets of hypotensive resuscitation — that’s for another blog post!). 

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So how do physicians get all of this lifesaving salt water into their patients, you ask. Well, the tried and true method that works 90%+ of the time is the peripheral IV, a needle with a plastic sheath over it that is inserted into a vein in one of your extremities. When the needle is removed, wallah, you have a nice plastic tube inside of a big fat vein just ready to receive fluid. Now IV’s have a few rather large downsides, the first being that even the big ones are actually somewhat wimpy with regards to the amount of fluid that they can carry in a given amount of time. If you really need to dump fluid into someone who is actively dying in front of you an IV just isn’t going to cut it! The second major issue with IV’s is that some people are really hard “sticks.” Got really dark skin and rolling veins? You’re a hard stick. Severely dehydrated or massively bleeding? Your veins are all collapsed and you’re a hard stick. Are you a former chemotherapy patient, an IV drug abuser, or a dialysis patient. You’re a really hard stick!

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A beautifully done IV, almost certainly placed by a nurse rather than a doctor! Don’t ever let a doctor poke you with an IV unless the doctor is an anesthetist or you’re dying and there no one else is around to do it! The nurses are the pros at this one folks.

Fortunately both of these issues, the low flow of IV’s and the difficulty of starting an IV on a “hard stick,” are readily solved with a central line. A central line is a really big needle + plastic tube that is inserted into a really big vein, a vein so big that it essentially never collapses and that can be located on anyone. There are three of these veins: 1) the femoral vein in the groin, 2) the subclavian vein underneath your clavicles (collar bones), and 3) the internal jugular vein in your neck. Now having a massive central line sticking out of your neck, chest, or groin obviously isn’t pleasant, but the chances are that if you need one of these you’re dying so the central line is the least of your worries, okay!

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An internal jugular vein (“IJ”) central line in a patient’s neck. Doctors usually use an ultrasound to guide placement these days, but in the past there was sometimes a bit of “fishing” involved in the procedure!

Central lines can take a while to insert and in some instances, like in a bouncing ambulance or in a Blackhawk helicopter, trying to place a central line borders on lunancy. And that’s when you go to the admittedly unappealing, but nonetheless lifesaving, intraosseous line (IO). An IO is basically a short central line that is drilled into either your tibia (calf bone) or your sternum (breast bone). Yes, I said drilled! The way that you place an IO is to either hand drill or electrically drill (with a medical drill, but it’s still a drill) the catheter into the bone until you hear a gut-wrenching “POP.” Then you flush the line and start to dump fluid into the patient to your heart’s desire.

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IO drills. Usually the tibia (the big bone in your calf) is the preferred site for an IO. However, in people who have lost their legs in accidents, to IED’s, etc. a sternal (breast bone) IO can be used. Using an excessively long IO needle for a sternal insertion is a really bad idea for obvious reasons! People have been known to make this mistake since tibial IOs are longer than sternal IOs.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 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.

References

1) Myburgh, JA and Mythen, MG. Resuscitation Fluids. The New England Journal of Medicine. September 26, 2013.

2) Somers, MJ. Maintenance Fluid Therapy in Children. In: UpToDate. Accessed September 30, 2013.

3) Dehydrated Man: http://en.wikipedia.org/wiki/File:Adult_cholera_patient.jpg

4) Man Dying of Massive Hemorrhage: http://www.flickr.com/photos/rafahkid/3155998947/

5) Urinal: http://www.flickr.com/photos/pointnshoot/261555819/

6) Table Salt: http://en.wikipedia.org/wiki/File:Himalaya-Salz-1.jpg

7) Cats on Raft: http://www.flickr.com/photos/31333486@N00/2441671268/

8) Normal Saline: http://en.wikipedia.org/wiki/Saline_(medicine)

9) Fractionated Blood: http://en.wikipedia.org/wiki/File:Blood-centrifugation-scheme.png

10) Peripheral IV: http://en.wikipedia.org/wiki/File:Intravenous_therapy_2007-SEP-13-Singapore.JPG

11) Central Line: http://en.wikipedia.org/wiki/File:Triple-Lumen.jpg

12) IO Line: http://en.wikipedia.org/wiki/File:Vidacare3productsystems.jpg

Biological Weapons of Mass Destruction

Unless you’re living in a cave, or perhaps a man-cave with your eyes glued to ESPN College Football, then you undoubtedly know that The United States is currently contemplating an attack against Syria in retaliation for the Assad regime’s use of chemical weapons against civilians. Since I already authored a recent article on chemical weapons of mass destruction, today I would like to discuss biological weapons of mass destruction, weapons which are even scarier than sarin or mustard gas. As always, the best way to understand complicated issues today, including the use of weapons of mass destruction, is to examine (briefly in our case) the history of these weapons.

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This is a photograph from WWI of blinded soldiers being led in a line away from a chemical weapons attack, the winds mercifully having changed directions and now blowing the deadly gas away from these victims. Many biological agents can be dispersed in a similar fashion, although the amounts needed to cause massive damage would be much, much smaller.

Biological weapons primarily consist of three categories of substances: bacteria, bacterial toxins, and viruses. Historically, the biggest killer on the battlefield wasn’t swords, bows, guns, or artillery — it was germs, especially typhus, which is caused by a bacteria that is carried by the human body louse (a rare parasite today thanks to modern hygiene, but very common up until at least World War I). The intentional use of biological weapons dates back to at least feudal times, when enemy armies would catapult the victims of plague (a bacteria), smallpox (a virus), and other nastiness over the walls of enemy cities. During World War II the Japanese extensively used both chemical and biological weapons against the Chinese, including the dropping of “plague bombs” from their aircraft into Chinese cities — essentially cannisters that were full of fleas carrying the bacteria Yersina pestis that causes bubonic plague (aka: “The Black Death”).

Shiro-ishii[1]

This is Shiro Ishii, the microbiologist and general who led Japan’s infamous Unit 731 during WWII. Unit 731 was responsible for Japan’s biological weapons program and also participated in dissections of living human beings and other horrific medical experiments that were performed on living, unanesthetized humans. Dr. Shiro Ishii was not punished for his crimes.

As terrible as these examples are, the greatest biological attacks in history have actually been unintentional. Nonetheless, these unintended “attacks” show us how potentially devasting an intentional biological attack might be — a scary prospect given that manufacturing biological weapons is actually pretty easy to do (anthrax probably lives in soil your backyard!!!). While “The Black Death” of Europe is probably the most infamous example of a massive pandemic decimating a population, having killed at least one person in three in 14th century Europe due to the inadvertent transmission of Yersina pestis infected rats/fleas aboard trading ships, the most poignant example of (mostly) inadvertent biological catastrophy actually occurred in the Americas and it is largely responsible for the cultural makeup of North and South America today.

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Florid smallpox afflicting a child.

Unlike Europeans, Africans, and Asians, who had lived in contact with one another and with one another farm animals (the initial source of many human pathogens), Native Americans had no innate resistance to smallpox, measles, and a host of other diseases that Europeans brought with them after Columbus’ monumental voyage of 1492. Although hard numbers are difficult to come by, it is likely that in many areas up to 90% of the native population died from these diseases in a very short period of time, ultimately making their conquest by Europeans much easier than it otherwise would have been. A particularly good example is The Pilgrims, who landed in Cape Cod to find fertile lands that were devoid of inhabitants and that just so happened to also be filled with lots of recently emptied villages. This was not a coincidence! European traders had visited the area shortly before The Pilgrims arrival and the bustling native population was ravaged by the diseases that they brought with them. Had the Pilgrims landed at any other time they would have certainly been driven off. However, the remaining Native Americans decided to put up with The Pilgrims because they thought that they might be useful allies against their adversary tribes, who had not (yet) been affected by European diseases — it seemed like a good idea at the time! By the way, if you want to read more on the topic of the European/Native American first encounters I highly recommend these two books, both of which I strongly based this paragraph upon — Mann, C.C. 1491: New Revelations of the Americas Before Columbus by Charles Mann and Guns, Germs, and Steel by Jared Diamond.

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The evolution of the wound/scar that forms after smallpox vaccination.

The mid-20th century marked a period of bustling research into weapons of mass destruction and biological weapons of mass destruction were no exception. At one point both The United States and The Soviet Union measured their biological weapons stockpiles in tons. The average car weighs 1-2 tons — a useful “yardstick” to wrap your head around how much of this stuff their was (is?) in the world not very long ago. The good news is that both The United States and the former Soviet Union, aka: Russia, began officially destroying their stockpiles of biological weapons during the 1990s. The only countries today with likely stockpiles of biological weapons that also publically have stated that they would consider using them in war are North Korea and Syria, the bad news being (for American readers) that we have officially been at war with North Korea since the 1950s and we are probably about to march off for a little adventure in Syria due to the regime’s recent blatant use of chemical weapons (probably sarin gas) against civilians. Before we look at specific types of biological weapons, here’s a list of countries that have or had biological weapons at one point in the not too distant past (courtesy of The Arms Control Association): Russia, The United States, China, Syria, North Korea, and Libya. Other countries which may possess or may have possessed biological weapons are: Egypt, India, Iran, and Israel.

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Bashar Al-Assad, the dictator of Syria, who is also an ophthalmologist by training (a medical doctor who specializes in eye surgery). The deathtoll is much higher now, by the way.

Types of Biological Weapons:

1. Smallpox: The only disease ever eradicated by the actions of mankind, smallpox was declared extinct by The World Health Organization in 1980 after a decades-long global vaccination effort. Smallpox was capable of killing in excess of 1/3 of its victims and of incapacitating most of the rest for periods of weeks to months. Those who recovered were often maimed for life with deep pockmarks over their faces and bodies Smallpox vaccination with a related bovine virus, cowpox, actually began long before Edward Jenner popularized the technique in 1796; indeed, after witnessing the effects of smallpox firsthand (he bore facial scars for the rest of his life), General George Washington began the practice of compulsory smallpox vaccination in the American (Continental) Army in 1777 that continues to this day. While an effective vaccine does exist for smallpox, there is no effective cure once you have the disease. Smallpox is an inviting biological weapon for both armies and for terrorists because the perpetrators of the attack could protect themselves before hand by being vaccinated. Most people, including most people in The United States, are no longer vaccinated against this terrible virus, which continues to live on in select laboratories in The United States and in Russia (other countries too?).

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An electronmicrograph of the smallpox virus.

2. Bubonic Plague: Bubonic plague is most commonly spread from infected rats (and other critters) to humans via fleas but it can also be spread through the air, both intentionally in the case of a biological weapons attack or simply by coughing from a person with pneumonic plague — bubonic plague that has spread to the lungs. Bubonic plague results in the massive enlargement of lymph nodes to form pus filled sacks under the armpits, in the groin, and in the neck of persons afflicted with this deadly disease, which kills up to 90% of untreated victims. Antibiotics can cure bubonic plague if the infected person gets them quickly and if there are still enough antibiotics to go around, a rather important caveat if a large city or cities were to be infected simultaneously with this horrible pathogen. Victims of the bubonic plague often turn black due to disseminated intravascular coagulation (DIC), a coagulation disorder that can be triggered by an overwhelming infection. In DIC the body forms excessive blood clots, runs out of the clotting proteins that are necessary to form blood clots, and then bleeds internally. Again, bubonic plague is an inviting weapon for modern militaries and terrorist organizations because soldiers can be pre-treated with antibiotics before plague is unleashed.

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A man dying from bubonic plague, aka The Black Death.

3. Anthrax: The bacterium Bacillus anthracis is a ubiquitious soil organism that, as I stated above, probably lives in the soil in your backyard. This organism rarely naturally infects humans and when it does it usually presents as a nasty skin infection that afflicts persons who work with dirty animals (cutaneous/skin anthrax is also known as “wool-sorters disease”). The problem with anthrax is that it is easy to make and that when this bacterium is aerosolized in the form of a concentrated powder it rapidly produces a fatal pulmonary (lung) infection. Anthrax can be treated with antibiotics but, frankly, unless you get them into your system quickly even these modern drugs don’t work very well for someone with fullblown pulmonary anthrax. There is also an effective vaccine and all American soldiers, myself included back when I was still wearing the uniform, are vaccinated against this disease before they deploy overseas. The combination of anthrax being preventable with vaccination and with the preventative early use of antibiotics again make this a “good” candidate for use as a biological weapon. We all know that there have already been several lonewolf anthrax attacks in The United States, first after the Sept. 11th attacks (perpetrator likely deceased) and again in April 2013 (the targets were President Obama and US Senator Roger Wicker of Mississippi — perpetrator still at large). It is both easy to make for someone with Bachelor’s degree level microbiology training and deadly…

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One of the Sept. 11th anthrax letters, this one having been sent to Senator Tom Daschle (the Senate Majority Leader at the time).

4. Ricin: This biological poison exists in a gray area between biological and chemical weapons. Ricin is a naturally occuring toxin that is produced by castro beans and that can be distilled from them using fairly rudimentary chemistry techniques. Ricin has been used in assasinations, the most famous of which was the assasination of a Soviet dissendent in London during the 1970s via ricin that was administered by poking him with an umbrella with a concealed hypodermic needle in its tip. This powerful poison can also be disseminated through the air and their is no curative treatment for the havoc that it unleashes inside the bodies of its victims. Ricin works by shutting down the production of proteins inside the body’s cells and this rapidly causes tissues such as the lungs, the liver, the kidneys, and the gastrointestinal tract to stop working (to put it simply), with death as the result.

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Castor beans, the source of ricin.

5. Viral Hemorrhagic Fevers: Include the feared Ebola virus, which kills up to 90% of exposed people in a particularly gruesome way — by causing them to bleed both internally and externally, with blood oozing from every bodily orifice as the victim’s life slips away. These horrible viruses are found in nature and they have no effective preventative vaccination or postexposure cure. This likely gives viral hemorrhagic fevers too many potential unintended consequences for any sane military to consider their use — the risk of the virus circling back and infecting your own people would likely be too great (unless there is a vaccine or effective antiviral treatment that no one else knows about…). These same properties likely make viral hemorrhagic fevers a tempting weapon for terrorists who don’t mind losing their own lives in the process, especially for terrorists who hail from places that are unlikely to be reinfected via routine global transit — like terrorists who live in prehistoric villages in Afghanistan, the tribal regions of Pakistan, or the nether regions of Yeman for example.

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Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 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.

References:

1. Emergency War Surgery: Third United States Revision. Department of Defense, United States of America. 2004.

2. Pickover, C.A. The Medical Book: From Witch Doctors to Robot Surgeons, 250 Milestones in the History of Medicine. Sterling Publishing, New York, New York. 2012.

3. Arms Control Association. http://www.armscontrol.org/factsheets/cbwprolif

4. Mann, C.C. 1491: New Revelations of the Americas Before Columbus.Knopf. 2005.

5. Riedel, S. Edward Jenner and the History of Smallpox and Vaccination. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/

6. CDC: Facts About Ricin. http://www.bt.cdc.gov/agent/ricin/facts.asp

7. Poison Gas Attack: Courtesy of Wikipedia. http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=biological+weapons&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=AUS5I1VchAloMM%3A%3Brz0CWPBHJlp6eM%3Bhttps%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F0%252F09%252FPoison_gas_attack.jpg%3Bhttp%253A%252F%252Fen.wikipedia.org%252Fwiki%252FChemical_weapons_in_World_War_I%3B713%3B262

8. Shiro Ishii/Unit 731: Courtesy of The Government of Japan and Wikipedia. http://en.wikipedia.org/wiki/File:Shiro-ishii.jpg. http://en.wikipedia.org/wiki/Shiro_Ishii.

9. Child with Smallpox: Courtesy of Wikipedia. http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=small+pox&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=kK0fifoo49WX2M%3A%3BiNBHHMAvHy4RzM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F6%252F66%252FChild_with_Smallpox_Bangladesh.jpg%3Bhttp%253A%252F%252Fen.wikipedia.org%252Fwiki%252FFile%253AChild_with_Smallpox_Bangladesh.jpg%3B1995%3B3040

10. CDC: Evolution of Smallpox Vaccine Scar: www.bt.cdc.gov.

11. Gasmask: www.photopedia.com. http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=biological+weapons+&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=IjTK3e2PVBxQeM%3A%3BBsUcnXtQGfx59M%3Bhttp%253A%252F%252Fimages.cdn.fotopedia.com%252Fflickr-2340497389-hd.jpg%3Bhttp%253A%252F%252Fwww.fotopedia.com%252Fitems%252Fflickr-2340497389%3B1620%3B1080

12. Smallpox Virus: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=smallpox+virus&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=t2MLkYzo_s_P1M%3A%3BWb1fAUxORmoNmM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252Fd%252Fd4%252FSmallpox_virus.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ASmallpox_virus.jpg%3B700%3B529

13. The Black Death: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=bubonic+plague&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=vbas0_EVeECZMM%3A%3B4BQtgg5Tgf9DOM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F0%252F0a%252FAcral_necrosis_due_to_bubonic_plague.jpg%3Bhttp%253A%252F%252Fen.m.wikipedia.org%252Fwiki%252FFile%253AAcral_necrosis_due_to_bubonic_plague.jpg%3B331%3B504

14. Anthrax Letter: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fanthraxmuseum.tripod.com%2Ftheanthraxmysterymuseumtm%2F&h=0&w=0&sz=1&tbnid=wHMn548pTuUnWM&tbnh=194&tbnw=259&prev=%2Fsearch%3Fq%3Danthrax%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=anthrax&docid=4oNxDVLII1jjHM&hl=en&ei=dVwlUt3nGcq7qAGX2IHQBQ&ved=0CAUQsCU

15. Castor Beans: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=castor+beans&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=V8B0kVUzGBJvcM%3A%3B_71waOagMkhaPM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F3%252F3d%252FCastor_beans1.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ACastor_beans1.jpg%3B1234%3B1195

16. Bashar Al-Assad. www.flickr.com.

The Best of Medicine on the Big Screen!

This is a list of some of the best portrayals of medical conditions on the Big Screen topped off with a sprinkling of excellent portrayals of medical conditions in otherwise non-medical themed movies. I thought that we’d have a little bit of fun today — enjoy!

The Madness of King George: King George III has recently lost the American Revolution and he now suffers from a strange form of delusional psychosis that seems to be precipitated by eating pears and that turns his urine blue! The unfortunate king, who despite the average American’s opinion of him actually was one of the more enlightened monarchs of the era, probably suffered from a rare genetic disorder called acute intermittent porphyria (AIP). AIP is caused by a genetic defect in the body’s ability to metabolize worn out hemoglobin, the iron-containing protein that enables your blood to efficiently carry oxygen to the rest of your body. People with AIP suffer from severe abdominal pain and from psychiatric symptoms. It’s a great movie that most people have never heard of — check it out!

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King George III is really a tragic figure. Unlike most other monarchs throughout history he wasn’t a womanizer and apparently had few, if any, major vices. He considered himself a man of the people and spent his free time farming in a large garden that he planted with his own two hands.

A Beautiful Mind: John Nash is one of the greatest mathematicians who ever lived, but he also suffered from a raging case of paranoid schizophrenia, a mental disorder characterized by delusions, hallucinations, and bizarre behavioral patterns. Fascinatingly, Dr. Nash actually learned to live with his disease and he functioned for years as a Princeton professor without taking any medications (this is extremely rare for a person with schizophrenia and generally a bad idea; Dr. Nash was fortunate to have exceptionally strong social support and a genius’ way of being able to work around problems, including his personal ones).

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Left: Hollywood John Nash. Right: The real McCoy. Crowe’s depiction of Dr. Nash later in the movie is really, really impressive by the way.

One Flew Over the Cuckoo’s Nest and The Changeling: Two very creepy and very realistic movies about what it was like to be a patient in a mental hospital in the not so distant past, when the rights of the mentally ill were essentially nonexistent. The Changeling is particularly disturbing because it is a true story about the political commitment of an inconvenient person (a mother whose child had been kidnapped) by the Los Angeles Police Department during the 1920s. The Changeling also describes one of the first known cases of a documented serial killer of children — it’s a great flick but not one to watch with the kiddos. For a more modern and less disturbing look at the mental health professions check out Good Will Hunting, a movie about a psychotherapist saving a talented young man from self-destruction and the movie that made Ben Affleck and Matt Damon into stars.

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Even though your girlfriend probably still hates her for breaking up Brad Pitt and Jennifer Aniston, Mrs. Jolie does a great job in this creepy film! It takes a while to really get going, but it’s worth the wait.

Rainman: Dustin Hoffman and Tom Cruise knock the ball out of the stadium with Hoffman’s portrayal of a man with severe autism and Cruise’s depiction of how hard it is to care for a loved one with this condition.

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Definitely Rainman.

King of California: Michael Douglas gives a spot-on performance as a man with bipolar mania and the grief that he causes his estranged daughter. Accurate, funny, and an all around great film that was ignored by the critics.

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Goodfellas and A Clockwork Orange: If you want to see a classic sociopath in action check out “Tommy” (Joe Pesci’s character) in Goodfellas. The dirt bag main character in A Clockwork Orange also hits the nail on the head and the movies description of classic conditioning techniques (one of the foundations of modern psychotherapy) is also spot-on. Trivia: What does Joe Pesci’s last name mean in Italian? Answer: Fish.

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What you call me, prick? Fish…I got yo’ fish!!!

The Abyss: If you SCUBA then you should definitely check this movie out, which is about a crashed U.S. nuclear missile submarine and a crazy Navy SEAL who tries to blow it up by detonating one of the nuclear warheads and nearly causes war with the Soviet Union in the process. Of course, everyone else (not wanting to be blown up in a nuclear explosion — go figure) is trying like mad to stop him. The SEAL is suffering from high pressure neurologic syndrome, a risk of diving to great depths that you’re unlikely to encounter unless you’re a professional diver for an oil company or the military. With that said, nitrogen narcosis is a common side-effect of SCUBA that is a risk to all divers and that shares many of the same symptoms, including altered mental status (you feel like you’re drunk) that progresses to severe somnolence and death (you fall asleep underwater).

Star Wars: What’s Star Wars doing on this list, you ask! Well, Darth Vader’s breathing machine is the answer because it’s nothing but a souped-up version of a mechanical ventilator, aka: “life support.” Check out my article on “What the Heck is Life Support” if I’ve got you interested.

Master and Commander: The ship’s doctor performs some really cool 18th-19th century medical procedures in this Napoleonic Wars naval flick that stars Russell Crowe in one of his better performances! From amputating an arm without anesthetic (it didn’t exist yet!) to draining a cranial hematoma (blood clot under the skull) with a burr hole, this film is as accurate as they come!

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Platoon and First Blood: Sergeant Barns in Platoon is a masterful depiction of untreated PTSD and Rambo: First Blood does an excellent job as well. Platoon is actually based on director Oliver Stone’s personal experiences as a grunt in Vietnam and it should be on everybody’s “to watch” list.

Superman (1978): Yeah, I’m talking about the one with Christopher Reeves and the reason that I mention this film (the only reason) is because Superman’s stepfather dies of a classic STEMI (major) heart attack at the beginning of the film, suddenly feeling short of breath and clutching his left arm in agony as he falls to the ground dead from sudden cardiac death. The classic symptoms are only present in a small minority of heart attacks, by the way — but the depiction is spot-on in this classic film.

The Dark Knight: This Batman film is remarkable for the way that Keith Ledger accurately represented tardive dyskinesia, involuntary facial tics caused by long-term use of antipsychotic drugs, in his portrayal of The Joker. Watch how The Joker’s tongue darts in and out of this mouth at random intervals throughout the film.

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My Nonfiction Books — Click on the Cover if You’re Interested!

Intrusive MemoryMedical School 101

 

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 16-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.

References/Images:

King George III: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.frontporchrepublic.com%2F2010%2F12%2Fmonarchy-and-the-american-constitution%2Fking-george-iii%2F&h=0&w=0&sz=1&tbnid=02xoYSWStykotM&tbnh=204&tbnw=246&prev=%2Fsearch%3Fq%3Dthe%2Bmadness%2Bof%2Bking%2Bgeorge%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=the%20madness%20of%20king%20george&docid=u_NtVJX8aukosM&hl=en&ei=lcTtUfbBNYrA9QSwkoHIDw&ved=0CAUQsCU

A Beautiful Mind: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&biw=1600&bih=752&tbs=sur:fc&tbm=isch&sa=1&q=A+Beutiful+mind&oq=A+Beutiful+mind&gs_l=img.3..0i10l10.2331.4975.0.5118.15.15.0.0.0.0.80.737.15.15.0….0…1c.1.21.img.7x973vvwotk&bav=on.2,or.r_qf.&fp=8bcd504da0d79f95&facrc=_&imgdii=_&imgrc=ptXC8XWenZONKM%3A%3B-IivOoQQR3aV1M%3Bhttp%253A%252F%252Ffarm5.staticflickr.com%252F4108%252F4845691040_be098082cc_z.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fjdxyw%252F4845691040%252F%3B320%3B475

John Nash: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&biw=1600&bih=752&tbs=sur:fc&tbm=isch&sa=1&q=A+Beutiful+mind&oq=A+Beutiful+mind&gs_l=img.3..0i10l10.2331.4975.0.5118.15.15.0.0.0.0.80.737.15.15.0….0…1c.1.21.img.7x973vvwotk&bav=on.2,or.r_qf.&fp=8bcd504da0d79f95&facrc=_&imgdii=aipfZxc4JZ0G6M%3A%3B0hh11B5Z5zdfoM%3BaipfZxc4JZ0G6M%3A&imgrc=aipfZxc4JZ0G6M%3A%3Bk_ZUFElW6stlfM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F9%252F91%252FJohn_f_nash_20061102_3.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253AJohn_f_nash_20061102_3.jpg%3B727%3B1000

The Changeling: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.amazon.com%2FChangeling-Angelina-Jolie%2Fdp%2FB001NFNFNU&h=0&w=0&sz=1&tbnid=ow3ht4iMPMz3-M&tbnh=268&tbnw=188&prev=%2Fsearch%3Fq%3DThe%2BChangeling%2Bmovie%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=The%20Changeling%20movie&docid=6g3vF-TQqV1JlM&hl=en&ei=88_tUd0Qhbb1BJPdgLgE&ved=0CAIQsCU

Rainman: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fthereviewbroads.com%2F2013%2F06%2Fpopular-casino-scenes-in-movies.html%2F&h=0&w=0&sz=1&tbnid=fH5gsHTDlvL__M&tbnh=165&tbnw=306&prev=%2Fsearch%3Fq%3DRainman%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Rainman&docid=2-azxDyULZZ4IM&hl=en&ei=j9DtUb7pJIHo8gSUoYGQAg&ved=0CAMQsCU

King of California: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&biw=1600&bih=752&tbs=sur:fc&tbm=isch&sa=1&q=King+of+California&oq=King+of+California&gs_l=img.3..0l2j0i5l2j0i24l6.2777.7384.0.7579.18.16.0.2.2.0.91.953.16.16.0….0…1c.1.21.img.nyRFJraU7wI&bav=on.2,or.r_qf.&fp=8bcd504da0d79f95&facrc=_&imgdii=_&imgrc=rthdAv21zvzBkM%3A%3Bocczy-FYKaVb8M%3Bhttp%253A%252F%252Ffarm3.staticflickr.com%252F2290%252F2496544558_9756f39810_z.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fphim%252F2496544558%252F%3B433%3B640

Goodfellas: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.gonemovies.com%2FWWW%2FWanadooFilms%2FMisdaad%2FGoodTommyMoeder.asp&h=0&w=0&sz=1&tbnid=sMtBJo4KBst4LM&tbnh=166&tbnw=303&prev=%2Fsearch%3Fq%3DGoodfellas%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Goodfellas&docid=EqubuvpxNrxE3M&hl=en&ei=RNHtUcH5H4vY9ASw8oDgCw&ved=0CAUQsCU

Master and Commander: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fnmedlock.wordpress.com%2F2011%2F04%2F26%2Fmaster-and-commander-vs-behind-enemy-lines%2F&h=0&w=0&sz=1&tbnid=tBZMrRTNt55a6M&tbnh=194&tbnw=259&prev=%2Fsearch%3Fq%3DMaster%2Band%2BCommander%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Master%20and%20Commander&docid=msPatd04cvPuvM&hl=en&ei=6NHtUbOWGpKy9gTWkICADA&ved=0CAMQsCU

The Dark Knight: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=the+madness+of+king+george&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=d8TtUbXIHMO0rgHcm4DgDg#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=Joker+The+Dark+Knight+&oq=Joker+The+Dark+Knight+&gs_l=img.3..0l10.3867.4732.8.5406.6.6.0.0.0.0.59.274.6.6.0….0…1c.1.21.img.ti3ZH_2cu0k&bav=on.2,or.r_qf.&fp=d10fcddc5d58554c&biw=1600&bih=752&facrc=_&imgdii=_&imgrc=KCVuURdycTQhMM%3A%3B_JkBrgApy2c3eM%3Bhttp%253A%252F%252Ffarm3.staticflickr.com%252F2252%252F2432121324_1b9c3d99d6_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fmorningmagician%252F2432121324%252F%3B1086%3B789

Mental Illness 101: Part 3/3

Posttraumatic stress disorder (PTSD) is caused by exposure to traumatic situations in which your life was threatened. PTSD was first noticed in combat veterans and it has had many names throughout history–“shellshock” in WWI vets and “Vietnam Vet Syndrome” in veterans of that awful war. In order for a stress reaction to meet the diagnosis of PTSD the symptoms–hypervigilance (being on edge all of the time), avoidance of things that remind you of the traumatic event (like the war veteran who avoids places with helicopters), and reexperiencing (nightmares, intrusive memories, or both)–have to be present for more than 3 months. A civilian form of PTSD is common in victims of near death expericences, of sexual assault, and of severe child abuse The disease is usually highly treatable in most cases with a combination of counseling and medications. A famous person with PTSD was Audie Murphey–the most decorated American soldier of WWII.

Attention deficit/hyperactivity disorder (ADHD) is pretty self-explanatory–a severe deficit of attention span and hyperactivity, usually in a child. People with severe ADHD greatly benefit from stimulant medications (e.g. Adderal, which is amphetamine); however, this disorder is probably grossly over-diagnosed. If your kid can’t function because of their poor attention span and hyperactivity then it is reasonable to have them evaluated by a psychiatrist for ADHD. With that said, the overuse of powerful stimulants, which stunt growth and are addictive, is a major concern and this is not a diagnosis that should be given out lightly (as it often is).

Tourette’s Syndrome is a highly debilitating tic disorder in which sufferers have some sort of tic that they cannot suppress–at least not for long. The classic form of Tourette’s disorder is a patient who regularly yells profanities and is unable to stop–something that can make leading a normal life next to impossible. The treatment is with powerful antipsychotic medications and supportive counseling.

Factitious Disorder is a psychiatric disorder in which patients create medical problems in themselves so that they can fill an emotional void in their life by getting attention from healthcare providers. The classic example is a nurse who secretly injects herself with large doses of insulin and then presents to the emergency room with a dangerously low blood sugar (that “can’t be explained”). Factitious Disorder-by-Proxy (Munchausen’s Disorder-by-Proxy) is similar, but instead of making themselves ill the perpetrator makes their children ill. This disorder is one of the worst forms of child abuse and it has a very high mortality for the child. My brothers and I are survivors of Munchausen’s Disorder-by-Proxy.

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!

Mental Illness 101, Part 2

Depending on the way that you crunch the numbers, either depression or anxiety disorders are the most common psychiatric illnesses. Depression comes in many forms, the worst of which is major depressive disorder—essentially really bad depression. Physicians have a neat little mnemonic to help us to diagnose depression, SIG E CAPS (5/8 = positive for depression)—Sleep changes; loss of Interest; Guilt; decreased Energy; decreased Concentration; Appetite changes; Psychomotor changes (either being more irritable or less responsive to the world than the usual you); and Suicidal ideations. Depression is a really big deal, both because suffering from depression ruins your quality of life and because about 1:20 people with severe depression end up committing suicide—that’s not as bad as the 1:10 people with bipolar disorder who end up committing suicide, but still a terribly high figure. Really, really severe depression can cause psychosis and this is especially common in postpartum depression—depression that strikes some women after childbirth. A common form of depression this time of year is Seasonal Affective Disorder (SAD), which occurs in susceptible people when they aren’t exposed to enough sunlight—this disease responds really well to some time out in the sun or a special UV lamp called a light box. The biochemistry behind SAD is quite interesting—the same gene that codes for melanin (the substance that makes your skin tan) also codes for a naturally occurring opiate, which is why being in the sun makes you feel good! Evolutionarily this probably occurred to ensure that we all got enough vitamin D, which our body makes when the skin is exposed to UV light from the sun. All forms of depression are highly treatable, so see your doctor immediately if you think that this might be you!

Anxiety Disorders include obsessive-compulsive disorder (OCD), social phobia, generalized anxiety disorder (GAD), and performance anxiety. OCD is characterized by obsessions (intrusive thoughts) that are temporarily relieved by the performance of compulsive rituals. The classic case of OCD is someone, like billionaire Howard Hughes in the excellent movie, The Aviator, who feels unclean or infected and constantly washes their hands because of it, drying their hands out and rubbing them so raw that they bleed. Social phobia is the fear of being around other people and in severe cases it can present with agoraphobia, a person who is afraid to leave their home, a debilitating condition that fortunately is highly treatable with medications. GAD is essentially excessive worrying to the point where it begins to compromise the patient’s quality of life—sometimes people with GAD can’t sleep because they are so worried about different things that are going on in their life. Finally, performance anxiety is typified by someone who is terrified of public speaking or by the musician who gets a nervous hand tremor each time he sets in front of his audience. Fortunately, all four of these disorders are highly treatable with medications and therapy in most instances—by the way, a general caveat of mental illness is that most of these diseases respond best when the patient is treated by both a psychologist (talk therapy) and a psychiatrist (primarily treats via psychiatric medications). PTSD is another anxiety disorder but it is very different from the four that we have discussed so far—we’ll pick up with PTSD tomorrow during Mental Illness 101, Part 3 (of an expected four part series).

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!