Monday, December 15, 2014

How sick was Peyton Manning before taking the field on Sunday afternoon? According to ESPN, Manning needed to be rehydrated with 4 bags of fluid and that translates into being really, really sick. But sick is relative and he was able to take the field…but there should have been a disclaimer during player introductions, that a professional athlete’s body is trained to recover well from adversity and this behavior should not be tried at home.

Each bag of IV fluid contains one liter of usually normal saline, salt water or Ringers Lactate, a balanced salt and electrolyte solution and its purpose is to replenish lost body fluids. In patients who are ill, fluid can be lost in many ways, from excessive sweating to cool the body and control its temperature, to fluids lost from vomiting and diarrhea. If the patient cannot drink enough water or other fluids to replace the lost fluid, dehydration will quickly occur and bad things can happen.

The body’s fluid is located within blood vessels (intravascular: intra=within +vascular=blood vessel), within cells (intracellular) and in the interstitial space, the areas between cells. The blood in our arteries and veins is a combination of red blood cells, which carry oxygen, and the intravascular fluid. There needs to be enough blood volume with each heart beat to supply the body with its energy needs. As the body dehydrates and the amount of fluid in the body decreases, sensors in the kidney and brain start shifting fluid between the different spaces. The goal is always to supply the vital organs (brain, heart, lung, kidney, intestine) with oxygen rich blood to maintain their function. Fluid is shifted from the intracellular space, from every cell in the body, and from the interstitial space into the intravascular space, so that blood pressure and heart function can be maintained. This works reasonably well in the short term until the body can rehydrate and recuperate.

Dehydration happens routinely during illness but when the body gets really dry, a downward spiral can quickly occur. Without enough blood flow to supply adequate water, glucose and oxygen for aerobic metabolism, cells switch to anaerobic metabolism, a mechanism that is doomed to failure. Byproducts of that metabolism alters the body’s acid base balance to the point where the lungs and kidneys fail to monitor and adjust the pH of the body. Soon cells stop working. If enough cells fail, then a whole organ can fail and if enough organs fail then the whole body is in peril. This is the definition of shock.

Peyton Manning’s statistics list him at 6’5” and 230 lb. Based on his 4 bags of IV fluids, he was almost 5 % dehydrated. Fortunately, with good kidney function that adjust electrolyte concentrations within the intravascular and intracellular spaces, there was no need for his doctors to micromanage the fluid composition and could use stock IV fluid off the shelf. That’s not always the case for people at the extremes of age (infants and elderly) or for those who take diuretic and other medications that affect the sodium and potassium levels in the body. Goldilocks micromanaging becomes one of the arts of medicine so that not too much or too little of a particular electrolyte is provided.

It is a testament to the athletic ability of Peyton Manning to recover from that level of dehydration to take the field. Aside from the myalgia, the muscle soreness that accompanies a flu infection, his muscle cells were also inflamed from each donating fluid to the intravascular space. The adrenalin of the game can help recovery but it takes some mental strength to not listen to one’s body and force it onto the playing field.

The advice for most who suffer from the flu is to rest, drink plenty of fluids and then rest some more. One should listen to their body and the level activity should be as tolerated. Presumably, this advice does not necessarily apply to NFL quarterbacks.

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collapsed lung

Sunday, December 7, 2014

The concept of transparency does not exist when it comes to trauma. For that reason, docs need a high index of suspicion when any victim walks or is carried through the door. The idea is this…most injuries can be taken at face value, but complications can exist, even in the most stable patient. For that reason, the concept of ruling out bad things is a routine thinking pattern in medicine. It does not mean that every test known to man has to be ordered, history and physical exam are powerful tools, but at least the doctor has to go through the mental gymnastics to be comfortable with the patient’s stability.

Every week, the NFL provides medical teaching moments. This time, it was learning that Dallas quarterback, Tony Romo, may have been playing for weeks with broken ribs. Bear receiver, Brandon Marshall goes down after a tackle, struggles to get up and ends up in the hospital with broken ribs and a collapsed lung. Same injury but Romo escapes without the complication that beset Marshall.

Breathing seems so simple and yet becomes very complicated when the chest wall is damaged. Normally, we breathe like a bellows, the ribs swing up and out, the diaphragm pushes down and air gets sucked into the lungs. That happens because the lungs are held against the chest wall by negative pressure between the two pleura, one lines the lung and the other lines the chest wall. Most people recognize pleural as the shiny skin when eating ribs. A pneumothorax or collapsed lung occurs when air gets into the space between those two linings and breaks the seal between the two. In trauma, a broken rib can cause a small tear into the lung tissue allowing that air leak to happen, but not always.


The pneumothorax is just one of the complications that have to be considered. It’s easy to be distracted by the pain of the broken fib and not concentrate on what’s important, the ability of the patient to breathe. The lung collapse is not all or nothing, it may be tiny and only seen as an incidental finding on a chest x-ray or Ct scan, it can be a complete collapse or the collapse can be somewhere in between. A smaller pneumothorax may not be appreciated on physical examination and for that reason a plain chest x-ray is an important screening tool in patients with chest injury. In addition to the collapsed lung, the doc will be looking for a contusion or bleeding in the chest. It is not meant to look for broken ribs. While more broken ribs presume increased force of trauma and increased risk of pneumothorax, the purpose of the test is to look for the lung damage and not any rib injury.

So Tony Romo keeps playing and Brandon Marshall goes to the hospital and gets a tube put in his chest. The way a traumatic pneumothorax is treated depends on how much air has escaped into the pleural space and how much the lung has collapsed. A tiny pneumothorax can be watched but larger ones need to have the air sucked out and the negative pressure re=established for the breathing mechanism to work again. A chest tube is placed through a stab incision in between the ribs and threaded into place. It is then hooked up to suct8ion and the patient is observed. If all goes well, the lung injury heals itself, the air leak stops and the tube can be removed in a couple of days. If all doesn’t go well, surgery may be required to repair the lung.

cchest tube

Aside from the lung, the ribs protect all sorts of vital structures from the heart and great vessels (think aorta, vena cava and others) in the chest, to the liver and spleen in the abdomen. Predicting the future is a fool’s game for doctors caring for trauma patients. Some, like Romo, will have an injury and do well. Others like Marshall will gradually decompensate with complications. Trauma is a worthy adversary and can lull doctors into a false sense of security when victims initially don’t look “too” injured. Just a reminder why medicine is a combination of science and art.


Image attriburions:, @bmarshall twitter feed



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