caffeine, concussion, compartment syndrome

Saturday, May 20, 2017

With every news report, opportunity lurks to learn about the underlying story, if only the writer or broadcaster would take a few minutes to explain. When the story is about medicine, it’s also most important to make certain that the facts confirm the situation. It’s no different than at the bedside, when the patient’s history has to make sense with the doctor’s diagnosis.

A couple parables drawn from the week’s news and a reminder and caveat that it is dangerous to practice medicine from press clips.


A sad story of a 16-year-old who had sudden death, collapsing at school. As reported by Lauren Sausser of the Charleston courier and Post, the autopsy was normal, including a normal heart. The coroner declared the death due to caffeine overdose, even though the toxicology report measured the serum caffeine level at 1.1 micrograms per deciliter and most toxicology references list the average lethal dose at 120 micrograms.

The Richland County coroner…acknowledged during an interview with The Post and Courier that this amount of caffeine shouldn’t have killed the Midlands teenager…case is controversial because some medical experts have doubted his conclusion. “They can talk to their experts. I’m going to use mine,” he said. He agreed the teenager’s death is “highly unusual,” but insisted his office “exhausted any other possibility.”

The story went viral making national and international headlines. The American Academy of Pediatrics reminded parents that caffeine is recommended for children. But the real story is that sudden death occurs when an abnormal rhythm, usually ventricular fibrillation or ventricular tachycardia, prevents the heart from squeezing in a coordinated way and not allowing blood to be pumped through the body. The only effective treatment is electricity, shocking the heart back into a normal rhythm, and it is why AEDs (automatic external defibrillators) need to be easily found in public spaces.

Sadly, a coroner decides he can’t find another cause of death, so he makes one up. If he had admitted that no cause was found other than unexplained sudden death, then the viral story might have talked about bystander CPR and AEDs.


The NFL and NHL are under siege when it comes to concussion diagnosis, treatment and prevention. Though it’s off season for football, Gisele Bundchen made news when she revealed that her husband, Patriots quarterback Tom Brady, had sustained a concussion in the past season. From the injury record, and reiterated by the NFL, there was no report of Brady suffering a concussion. Bundchen’s loyalty to her husband’s career was questioned. Why would she leak such a secretive story? And why didn’t the team or the league know that he had had a concussion?

The diagnosis of concussion is not easy, Symptoms may be subtle and delayed and perhaps only recognized well after the game where the injury occurred. It may be family that recognizes changes in personality with irritability or a change in sleep pattern, either insomnia or excessive sleepiness. The consensus statement of the most recent conference on sports related concussion held in Berlin in 2016 noted the following:

There is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC (sport related concussion) in the sporting environment.

The storyline should have focused on the need for family members and friends to be the extended nursing providers who can detect symptoms after a head injury, whether it occurred at work, riding a bike or playing in the park. Those who know the victim well are in the best position to observe changes in personality and function.

Emergency Surgery


Ryan Johansen underwent emergency surgery after hurting his thigh in the Nashville Predator playoff game. The NHL chooses only to release vague injury reports and it is up to the reader to guess what might be going on.

Emergency surgery is a big deal and there are few time when a patient needs to be rushed to the operating room. A few examples include:

  • Major trauma with internal bleeding and a patient who is so unstable and in shock that there is no time to wait for less invasive treatments
  • Bleeding in the brain with increased pressure in the skull (increased intracranial pressure) so that the blood clot has to be removed and the bleeding control to prevent further brain damage
  • An arterial blood clot that stops blood supply to an arm, leg or intestine. Timing of the essence to restore the blood supply, otherwise tissue quickly begins to die.

Otherwise, there may be an urgency to operate ,but surgery can be delayed until the patient’s condition has been optimized to minimize complicat8iosn from the operation or the anesthesia.

For Johansen, not a lot of emergencies exist in the thigh. Broken bones don’t need emergency treatment unless there is an open fracture, the skin overlying the fracture is torn and there is a risk of infection. Torn ligaments or tendons don’t need emergency repair. But perhaps it was compartment syndrome. In the thigh and other places within the body, muscles are contained in compartments with tight bands of tissue surrounding them. If the muscle is damaged and swells or bleeds excessively, the pressure within the compartment can rise. If it increases enough, blood flow through the area is compromised and muscle can die.

The treatment is emergency fasciotomy, where the compartment tissue is fileted open to allow the muscle to expand. This is an unusual injury but a good lesson for the public to know that keeping injuries iced and elevated can help prevent swelling and its complication.

Three stories, three lessons. Three opportunities for a parable to teach lost. And a reminder that one should not practice medicine based on newspaper, internet and television reports.





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the downside of supplements

Tuesday, January 3, 2017

It’s a new year and people fill it with resolutions to eat better, work out a little more, get in shape and be healthy. As January 1st shows up in the rear view mirror, the best intentions fall nu the wayside and sometimes people turn to a pill or supplement as an opportunity to regain momentum or perhaps replace the time and effort that being healthy entails.

When an athlete fails a drug screen, the response and excuse often is that the pill/powder/liquid was adulterated. The athlete did not know what was in the supplement or medication and there was no intent to cheat or gain a competitive advantage. Aside from Lance Armstrong and the recent Russian sports machine drug abuse indictment, most athletes have their transgressions and suspensions forgotten with time. Sammy Sosa, Barry Bonds and Roger Clemens are on the ballot for Cooperstown. But the reality is that role models do affect public behavior and the New Year has a few stories that are reminders that performance enhancement opportunities are wide spread and can be dangerous.

Caffeine jump starts the world in coffee, soda and also in energy drinks. That is not necessarily a good thing, because the concept of “everything in moderation” can be overwhelmed by “if a little is good, a lot must be great.”  Research from the US military has found that energy drink abuse leads to sleep pattern disturbances and is associated with service members falling asleep on duty. The conclusion of a Walter Reed study of more than 1, 000 soldiers found that energy drinks are “unregulated and can have negative side effects…those who had three or more drinks per day were more likely to fall asleep during briefings or on guard duty.” The authors of the report also concluded that the long term effects of larger doses of the ingredients in energy drinks is not known. Imagine if the FDA released the same statement for a prescription drug.

The Armed Forces report deals with adults but what about supplements that are being advertised and supplied to kids? The American Academy of Pediatrics has a policy position recommending against the use of creatine and testosterone products in the pediatric (under 18) population. But what stops a middle or high school athlete from walking into a health food store and buying products that have not been found safe for their use…it seems absolutely nothing. Research to be published in the Journal of Pediatrics found that health food sales people had no trouble recommending creatine and testosterone boosters to researchers posing as a 15 year old high school athlete. There are no laws that prevent such recommendations or sales. Trusting the recommendation of a supplement shop sales clerk is not the same as a discussion with a pharmacist.

 So who cares? The supplement manufacturers should maintain strict standards as to what is in their product and the consumer should be reassured that the product label accurately lists what is contained in a pill or powder. If only the consumer could be that certain. It remains a buyer beware marketplace. In 2015, the New Your Attorney General’s office found that Walgreens’ Walmart, Target and GNC all had supplements on their shelves that did not contain the ingredients that were documented on the label. Almost 80% of the supplements did not contain the medicines they were supposed to, but instead included “cheap fillers like powdered rice, asparagus and houseplants, and in some cases substances that could be dangerous to those with allergies.” The story made headlines for a day or two as the stores agreed to reach out to their suppliers. After another New Year has passed, how that story has played out is uncertain.

 For all the criticism leveled at the Federal Drug Administration, at least the US public can be reassured that the medications prescribed by a physician and dispensed by a pharmacist, will have the ingredient in the pill that is labelled on the bottle. The same holds true for hundreds of over the counter medications like aspirin or Tylenol and their generics. While we might not like the ads or commercials of some drugs, at least we know that their labs and production facilities are regulated to a high standard. When it comes to herbal supplements…not so much. It’s very much a buyer beware marketplace.

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