lessons learned from the playing field

Monday, January 18, 2016

Learning about medicine from the playing field.

Randall Cobb of the green Bay Packers, leaps to catch a pass, lands awkwardly and sustains a pulmonary contusion, or bruised lung. After coughing up some blood, never a good thing but many times not disastrous, he is observed in hospital and is discharged home where his lung will slowly heal, just like any other bruise. The injury is a reminder that with chest trauma, and many people fall and hit their ribs, the x-rays done are to evaluate the lungs and not the bones. Doctors are more interested in whether there is a collapsed lung (pneumothorax) or lung contusion, while the patient is more interested in whether there is a broken rib. Regardless of whether the ribs are bruised or broken, the treatment is the same: pain control so that the patient can take a deep breath and expand the lung to prevent pneumonia, the most important complication of a minor chest injury.

Steeler receiver, Antonio Brown, suffered a concussion in the game against the Cincinnati Bengals and within 24 hours there were reports that he would be recovered within the week to play in the team’s next game. He did not. After his concussion, Green Bay Packer, Sam Shields took a month to recover before play9ing again. It is a reminder that there is no way to predict the brain’s path to recovery from concussion and there is no definitive test to determine that a brain has fully recovered and is able to withstand another blow. No matter the NFL protocols, concussion remains a diagnosis made at the bedside and return to play has no standard playbook to follow.

finger bony anatomy

Carson Palmer of the Arizona Cardinals had a new splint on the right index finger of his throwing hand to protect the PIP joint that had been dislocated. Fingers have three joints (the thumb has two), the metacarpophalangeal (MCP) that connects the finger to the hand, and the proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joint. The PIP joint is commonly dislocated and can heal relatively easily but because of the complex anatomy of the hand, the bones can damage the tissues and tendons that surround the joint when they dislocate. Complications include a volar fracture of the thin plate of bone on the palmar surface of the joint can be broken, leading to joint instability and a boutonniere deformity where the tendons slide to the side of the joint and prevent the finger from completely straightening. It’s a reminder that hands are complicated and minor injuries may lead to major long term complications.

Joakim Noah of the Chicago Bulls dislocated his shoulder and will undergo surgery to stabilize the joint. In most people, surgery is not the first step in rehabilitation. They are allowed to undergo physical therapy to strengthen the shoulder and return range of motion before considering an operation. But in athletes or those who may not be able or willing to limit their activities, surgery is often the first and potentially curative step. Studies of young athletes and military recruits, that surgery after the first shoulder dislocation can prevent future dislocation 95% of the time. Without an operation only 5% will have stable shoulders. The reason has to do with the inherent instability of the shoulder. It is designed to have a wide arc of range of motion in all directions and for that reason, the surface area of bone in the joint is very small. The stability has to do with the soft tissues that hold the shoulder together from the capsule and the labrum to the ligaments and surrounding muscles.  When the shoulder dislocates, all these structures are damaged and stretched. Surgery, either arthroscopic or through an incision, is meant to tighten all the structures that have been torn apart. Rehabilitation takes months to return range of motion and power; Mother Nature does not like to be rushed when she heals soft tissues.

More lessons from the playing field next week.

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internal bleeding and high tech non-surgery

Monday, December 14, 2015

A year ago, Alex Smith of the Kansas City Chiefs fractured his spleen. A month ago, Indianapolis Colts’ quarterback, Andrew Luck, broke his kidney. Last week, San Jose Shark Logan Couture, tore an artery in his thigh.  A generation ago, all three would have undergone major surgery, but technology advances quickly in medicine and has made these disastrous injuries, potentially less disastrous.

ct abdomen

It comes down to being able to look inside the body without having to make an incision. The clinical decision to operate was once  made by a surgeon at the bedside, based upon history, physical exam and the stability of the patient. Exploratory surgery in the stable patient has been replaced with CT scans and angiograms. The ability to stop internal bleeding has become part of the skillset of the interventional radiologist. In trauma situations, the surgeon and radiologist are able to sometimes decrease the need for emergency operations and save some organs, like the spleen and kidney, that only a few years ago had to be removed.

Surgeons like to operate and no doubt that is why they tolerate years of training, to be able to hone skills that lets them cut into the body. In trauma, though, many patients are relatively stable when they present to the emergency department. That means they are awake and have normal vital signs including blood pressure and pulse rate. This gives time to figure out whether what injuries are present and whether a trip to the operating room is needed. All bets are off when the patient is hypotensive (low blood pressure) and seems to be bleeding to death. In this situation, going to the OR emergently seems most prudent, reasonable and the lifesaving thing to do. But if the patient is stable, technology can help look inside the body and sort things out.

In the trauma situation, a FAST scan (Focused Assessment with Sonography in Trauma) can use ultrasound at the bedside to look for blood in the abdomen, chest and surrounding the heart. If the ultrasound shows blood and the patient is unstable, it’s off to surgery as soon as possible. If, however, the patient is stable, a CT scan may be used to look inside the abdomen for injuries to the solid organs like the liver, spleen or kidney. Once upon a time, damage to those organs meant an automatic trip to the OR, but research and experience has shown that the body can heal itself relatively well and damaged organ parts may not need to be removed. With a dye injection that is part of the trauma CT, bleeding arteries can also be identified and instead of rushing to the operating room to tie off a bleeding artery, an interventional radiologist may become the hero of the moment. Threading a catheter though the femoral artery in the groin, the specific bleeding blood vessel can be identified and clotted off, sometimes preventing major surgery.

Spleen injuries are not uncommon, especially if the lower left ribs that protect the organ are damaged. Often the bleeding is contained within the spleen and nothing more needs to be done, other than watch it heal. This is the Alex Smith situation. The diagnosis led to close observation and a few months of healing. The spleen is an important organ that helps filter damaged cells from the blood stream and also plays an important role in the body’s immune system. It is much preferable to have a spleen than not.

For Andrew Luck, he was unlucky enough to fracture his kidney. The kidneys sit in the right and left flank and are protected by the lower ribs and thick back muscles. Still, a blow to the area can damage the kidney by breaking it and causing extensive bleeding. It is better to preserve a kidney instead of having it taken out, and CT can check out the anatomy, injury pattern and risk of bleeding. often, the kidney does fine if it’s left alone. But if needed to be removed, it is fortunate that the kidneys come in pairs and losing one is not necessarily a disaster.

The anatomy of the kidney and the spleen are somewhat similar in that both have segments or poles that have distinct blood supplies. If only part of the organ is damaged and continues to bleed, the radiologist can intervene and control that bleeding and still preserve the rest of the kidney or spleen by the threading technique to find and clot the offending artery.. The organ part without blood supply dies but this is a much better situation than needing to cut into the body. and hack it out. This ability to attack a single blood vessel also saved Logan Couture from having his thigh sliced open to find the bleedig artery in his thigh and tie it off. Instead, the internal bleeding was control in a very high tech way.

Technology has changed how medicine is practiced, especially with the ability to look inside the body. Future generations of physicians and surgeons will look at the care provided in the 21st century as barbaric, yet it’s what we have and it’s better than what we had. The only people who might bemoan the advances are surgeons who marshal their enthusiasm to operate with the understanding that it’s important to pick their patients wisely. In the right situation, the mantra of  “a chance to cut is a chance to cure” has been replaced with “good things come to those who wait”  and “patience is a virtue”.

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