cte, dui, second opinions…3 dot

Saturday, September 23, 2017

Thoughts from the week. More three dot …

CTE may not be as chronic as the name implies. Changes of chronic traumatic encephalopathy were found in the brain of Aaron Hernandez, a former NFL player, who committed suicide while in jail after being convicted of murder…The disease, which can only be diagnosed by autopsy is thought to be a consequence of concussion. Tau proteins are deposited in the brain and eventually are thought to affect cognition, and cause mood swings and depression. The theory suggests that the NFL puts players at high risk because of repeated concussions, but with CTE found in brains of high school and college students, it may be that NFL players have a higher incidence of CTE because they are studied more frequently and that their brains were damaged at a much earlier age…Boston University researchers found that those who participated in youth football before the age of 12 had a twofold risk of problems with behavioral regulation, apathy and executive function and a threefold risk of clinically elevated depression scores. The average age of subjects was 51 and included high school, college and NFL players.

Viking quarterback Sam Bradford, he of two knee ACL reconstructions, developed knee swelling as the NFL season began and after missing another game, it has been reported that he has sought a second opinion regarding potential treatments (presumably surgery) from Dr. James Andrews, one of the country’s leading orthopedic experts…Some might wonder why the Viking team doctor isn’t good enough to treat a star player, but to Mr. Bradford’s credit, another opinion is never a bad decision. In medicine, there are always different ways of doing things and if there is time to consider options, the wise patient should seek those out…The second opinion opportunity isn’t limited to pro athletes, but available to almost all. When it comes to deciding about an operation, a surgeon should welcome the request for a second option, and then help arrange it, providing names of reputable colleagues to review records and examine the patient…It should raise a red flag when a surgeon refuses or appears insulted.

Attributed to either William Gladstone or Willian Penn, “Justice delayed is justice denied” was taken to hear by the British court system in convicting and sentencing Wayne Rooney in a drunk driving case this past week…After being arrested in the wee hours of September 1, the British international soccer star, pled guilty to the charges of driving drunk. On September 18, his driving privileges were revoked for 2 years and he was sentenced to 100 hours of unpaid work as part of a 12-month community service order. He could have been sentenced to 6-months prison for his first offence…British courts have been cracking down on this behavior in light of an average of 940 deaths a year in England and Wales…By comparison, 10,000 victims die every year in the US…And Wisconsin considers a first offence DUI as a misdemeanor and 448,000 drivers have at least one DUI.

Greg Olsen, Carolina Panthers tight end, broke his foot and required surgery to insert a screw into the 5th metatarsal. He knew that something was wrong as he walked off the field…  Cleveland Browns receiver, fell awkwardly and hurt his hand but it was a day later that the broken bones were confirmed…David Johnson of the Arizona Cardinals had a dislocated wrist but continued to play. Just three examples that just because you can walk on it or move it, doesn’t mean that it isn’t broken. All it means is that the muscles and tendons that are associated with the area are working just fine. Walking stops when a bone or joint is deformed and cannot tolerate any movement, cannot support the weight of the body or the muscle/tendon is torn and cannot move a joint.

And a couple definition reminders:

  • A break, fracture, crack all describe the same injury,
  • a stretched or torn tendon is called a strain
  • a stretched or torn ligament is called a sprain. By definition an ACL tear is a sprained knee.
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alcohol, marijuana and dui

Monday, July 17, 2017

Things that I think I know but are probably just my opinion, and there are lots of numbers.

The NFL and Minnesota Vikings suspended Michael Floyd for the first 4 games of the 2017 season after he was convicted of extreme DUI in Arizona. In December, Mr. Floyd was found asleep at the wheel of his SUV with a blood alcohol level was measured at 0.217. His NFL suspension is in addition to the court’s punishment of 24 days in jail and 96 days of house arrest. It took just a little while for the NFL to react.

Drunk drivers are not beloved in the ER. It has to do with the sad knowledge that more than 10,000 people die each year associated with a DUI, either as the driver or the victim of their crime.

There is difficulty in decision making. Is the patient being belligerent or very quiet because of the effect of alcohol? or is there an associated head injury? In a larger hospital, the decision point is easy…the trauma patient with altered mental status, regardless of whether alcohol is involved gets a CT scan to look for bleeding. In a rural setting, where there isn’t a CT scanner on every corner, the decision is grayer whether the patient should be transferred by ambulance for an emergent scan. In foul weather (think blizzard or monsoon) that transfer decision may put other people, like EMTs and paramedics at risk. Watchful observation may be appropriate but there is little backup if things go south and that puts the patient at risk. And should the transferring ambulance leave the area for a prolonged transfer, those people in the vicinity may be left without any emergency transportation.

Those who drink and drive are not in the minority and there are a whole lot of people who make poor choices. According to the Centers for Disease Control and Prevention, 1.1 million people were arrested for driving under the influence. However, based on national surveys, there were more than 111 million self-reported instances of impaired driving in 2015. It seems that as a nation, we are very fortunate that “only” 10,000 people died.

Alcohol remains the drug of choice by people who drive while impaired, but marijuana use is increasing, with more than 1 in 8 weekend and nighttime drivers having the drug in their system. Having that marijuana in your system increases the risk of a crash by 25%.

Just a reminder:there is no legal limit of alcohol intoxication. The legality has to do with the activity being performed:

  • It’s de facto illegal to drive a car with an alcohol level greater than 0.08 BUT one can be found to be impaired at lower levels depending upon function
  • The legal limit to drive a commercial vehicle with a CDL (commercial drivers license) is 0.04
  • 0.04 is the same limit that the FAA imposes to fly an airplane
  • There is no limit for a surgeon to operate, but most of us would hope that level is absolute zeroThere is no legal limit to walk on the stree
  • The legal limit for a minor is zero

As for marijuana, whether the drug is prescribed for a medical situation or used recreationally, there are legal limits. Quoting from the Colorado Department of Transportation: Colorado law specifies that drivers with five nanograms of active tetrahydrocannabinol (THC) in their whole blood can be prosecuted for driving under the influence (DUI). However, no matter the level of THC, law enforcement officers base arrests on observed impairment”

 Widespread legal marijuana use is a new phenomenon and it will be interesting to see the effect on the frequency of impaired drivers on the road and the numbers of their vicitims in the ER.

When it comes to alcohol, emergency department doctors, nurses and techs care for a lot of drunk people, whether it is due to intoxication, withdrawal or trauma. Mr. Floyd is just one of the more than 3.8 million intoxicated patients who need care every year. And he is not the only celebrity, sports star who has made a significant error in judgement. He’s fortunate , however, that he fell asleep at the wheel while his car was stopped. Perhaps it was his potential victims who were thankful that he didn’t fall asleep driving 70 mph on the interstate and crashing into their school bus.

And those are just some of the things that I think I know…at least that’s my opinion.




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